Learn to : Learn to


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Learn to :

  • Learn to :

  • Understand sting reaction types

  • Recognize responsible insects

  • Understand risk factors

  • Understand basic treatment of stings

  • Understand when and how to immunize

  • Understand when to stop immunotherapy





Insect sting allergy in Italy:

  • Insect sting allergy in Italy:

    • Factory workers - 65% have been stung, 2.8% anaphylaxis. (similar to reported incidence in most temperate nations)
    • Foresters - 68% have been stung, 4.5% anaphylaxis (not significantly higher)


Insect sting allergy in Switzerland, Canton Bern (940,000 pop.):

  • Insect sting allergy in Switzerland, Canton Bern (940,000 pop.):

    • Annual incidence of severe anaphylaxis (with circulatory shock) was 6 / 100,000


26.5% U.S. prevalence of venom sensitization (27.1% in Germany)

  • 26.5% U.S. prevalence of venom sensitization (27.1% in Germany)

  • > 0.5 to 5% U.S. Severe insect sting allergy

  • > 40 deaths / year U.S. from insect stings

    • (does not include suspicious sudden deaths)


Frequent stings, especially < 2 mo. apart, sensitize

  • Frequent stings, especially < 2 mo. apart, sensitize

  • Very frequent stings, > 50 / yr, desensitize (beekeepers)



Stinging insects are order Hymenoptera (membrane-winged insects)

  • Stinging insects are order Hymenoptera (membrane-winged insects)

  • Apids (honeybees and bumblebees)

  • Vespids (yellow jackets, wasps, hornets, and paper wasps)

  • Formicids (ants, fire ants)



Domestic honeybees do not sting unless provoked

  • Domestic honeybees do not sting unless provoked

  • Bumblebees are not aggressive & rarely sting, but use in greenhouses increases exposure

  • Africanized hybrid honeybees, common in Mexico and South, are hostile, aggressive, and swarm





Bees leave their barbed stinger and venom sac implanted in their victim

  • Bees leave their barbed stinger and venom sac implanted in their victim

  • This distinguishes honeybee stings from all other stings: bumblebees, wasps, and ants have no barbs







Honeybee venom is very sensitizing

  • Honeybee venom is very sensitizing

    • More likely to react on re-sting
    • More likely to react during immunotherapy treatments
    • Less likely to be protected by immunotherapy
    • Less likely to stop immunotherapy


Africanized bees and domestic bees have identical venoms

  • Africanized bees and domestic bees have identical venoms

  • Africanized bees are much more dangerous due to easy arousal, aggressive stinging, mass stings, and persistent pursuit of the victim





Yellow Jackets: ground nesting; very aggressive & swarm - stings cause skin infection

  • Yellow Jackets: ground nesting; very aggressive & swarm - stings cause skin infection

  • Hornets, Wasps, and Paper Wasps : aerial nesting - in trees, roof overhangs, shutters, under shingles, in attics; not aggressive unless disturbed



Imported Fire Ants found in SE and Gulf coast; will spread much further north & west from global warming

  • Imported Fire Ants found in SE and Gulf coast; will spread much further north & west from global warming

  • Ants bite, and deliver multiple stings in circular pattern; aggressive & swarm - attacks 6 - 60% of people living in an area during each year.

  • Harvester Ants (native fire ants) found in SW; stings painful, but fatalities rare





Venom allergens are proteins or peptides : (Phospholipases, Acid Phosphatases, Hyaluronidases, Antigen-5 Neurotoxin)

  • Venom allergens are proteins or peptides : (Phospholipases, Acid Phosphatases, Hyaluronidases, Antigen-5 Neurotoxin)

  • Venom toxins are mostly small mediator molecules : histamine, serotonin, kinins, acetylcholine, dopamine, norepinephrine

















Immediate Allergic

  • Immediate Allergic

    • Local, Large Local, Systemic
  • Delayed Toxic (Non-Allergic)

    • Serum sickness, CNS demyelination, vascular thrombosis, glomerulonephritis, myocarditis, multi-organ failure, and death
    • Multiple stings required :
    • LD50 (honeybee) > 500 stings


Rapidly remove all bee venom sacs - envenomation is complete in one minute !

  • Rapidly remove all bee venom sacs - envenomation is complete in one minute !

  • Use your HIVE TOOL !



Honeybees (especially Africanized) or Wasps (yellowjackets and hornets)

  • Honeybees (especially Africanized) or Wasps (yellowjackets and hornets)

  • Without treatment, > 20-200 wasp stings or > 150-1000 bee stings can be fatal

  • Symptoms may not appear for hours to several days

  • Go to the hospital immediately for any mass sting (call 911 !!!)



Local: pain, redness at site

  • Local: pain, redness at site

  • Large Local: swelling of extremity

  • Systemic: generalized, involves any symptoms at a remote site from the sting. These may quickly be life threatening.



Local reaction: ice, antihistamine

  • Local reaction: ice, antihistamine



Large Local reaction: ice, antihistamine, prescription prednisone

  • Large Local reaction: ice, antihistamine, prescription prednisone



Systemic reactions: give epinephrine & treat for anaphylaxis. Call 911 !!!

  • Systemic reactions: give epinephrine & treat for anaphylaxis. Call 911 !!!



Treat immediately !

  • Treat immediately !

  • If you think of epinephrine, USE IT !

  • Epinephrine 1:1000 (0.01ml/kg) = 0.3 ml adult, 0.15 ml child. Inject into muscle !

  • Be ready to Re-Treat. Epinephrine may only last 5-10 minutes.



Epinephrine is required more than once in 35% of anaphylaxis cases

  • Epinephrine is required more than once in 35% of anaphylaxis cases

  • Most insurance companies cover dual packs of epinephrine injectors. Buy them !





CALL 911

  • CALL 911

  • Keep giving Epinephrine, as often as needed to control symptoms

  • If patient has asthma, USE THEIR INHALERS

  • If available, give oral Antihistamine and Oxygen



Give Glucocorticoids

  • Give Glucocorticoids

  • Consider Vasopressin, Heparin, Glucagon

  • Treat shock : fluids, pressors

  • Be prepared to intubate, suction, ventilate

  • Transport immediately by ambulance

  • Consider dialysis and plasmapheresis to remove inflammatory mediators & venom components



Urticaria pigmentosa - mastocytosis is a major risk factor for fatal sting

  • Urticaria pigmentosa - mastocytosis is a major risk factor for fatal sting

  • Dx is often unexpected (7% of sting pts)

  • Dx by high blood tryptase levels

  • Immunotherapy essential, but not fully protective

  • Consider lifetime immunotherapy

  • Consider drug prophylaxis (H1 & leukotriene blockade)



Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Haeberli G, Bronnimann M, Hunziker T, Muller U. Clin Exp Allergy . 2003;33:1216-20

  • Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Haeberli G, Bronnimann M, Hunziker T, Muller U. Clin Exp Allergy . 2003;33:1216-20

  • Constitutively raised serum concentrations of mast-cell tryptase and severe anaphylactic reactions to Hymenoptera stings. Ludolph-Hauser D, Rueff F, Fries C, Schopf P, Przybilla B. Lancet . 2001;357:361-2

  • Krishna MT, Fearby S, Annila I, Frew A. Hymenoptera stings and serum tryptase. Lancet. 2001 May;357:1527-8

  • Mastocytosis associated with severe wasp sting anaphylaxis detected by elevated serum mast cell tryptase levels. Biedermann T, Rueff F, Sander CA, Przybilla B. Br J Dermatol . 1999;141:1110-2

  • Fatal anaphylaxis after a yellow jacket sting, despite venom immunotherapy, in two patients with mastocytosis. Oude Elberink JN, de Monchy JG, Kors JW, et al. J Allergy Clin Immunol . 1997;99:153-4



Clinical History - helps with treatment Important to Identify:

  • Clinical History - helps with treatment Important to Identify:

  • what kind of insect

  • type of reaction

  • severity of reaction

  • ? progression of this reaction over time

  • ? worse compared to last sting



Winged / flying eliminates Fire Ants

  • Winged / flying eliminates Fire Ants

  • Stinger left in skin : Honeybee

  • Nest location : ground favors Yellow Jacket (bumble bee less common)

  • Large size: favors Hornet

  • Narrow waist: not a bee or bumblebee



Strong cross-reactivity occurs between :

  • Strong cross-reactivity occurs between :

    • Bumblebees and Honeybees (not total)
    • Yellow Jackets & Hornets
    • Paper Wasps (Polistes sp.)
    • Fire ants (Solenopsis sp.)
  • Cross-reactivity between different families is not clinically useful



Braun 1925, Benson 1930

  • Braun 1925, Benson 1930

    • Used honeybee abdomen, venom sac, and venom extracts to skin test and immunize
  • Schwartz 1965

    • showed frequency of positive skin tests to whole body extracts was no greater than in un-stung, pollen-allergic patients
    • therefore, venom testing is preferred


Venom extracts for bees & wasps available since 1978

  • Venom extracts for bees & wasps available since 1978

  • Venom proved superior to whole body extracts in preventing reactions

  • Exception: only whole body extracts available for fire ants - shown to be effective



About 90% of stings are from Wasps

  • About 90% of stings are from Wasps

  • Always test Yellow Jacket (most aggressive, most likely to sting)

  • If Wasp or Hornet is likely, test all local species

  • If Africanized bees are local, test Honeybee



If stinger found, test Honeybee

  • If stinger found, test Honeybee

  • When unsure, test Honeybee & Yellow Jacket

  • If stung by Bumblebee (large bee), test for Honeybee and Bumblebee

  • If poor history, test all local species



IgE:

  • IgE:

    • To identify culprit insect ( may be falsely negative in 15-20%)
    • To determine degree of sensitivity
    • To differentiate toxic and allergic Rxn
    • For Safety, prior to Skin Testing
  • IgG :

    • To check progress of desensitization


If blood test is negative, and suspicion of allergic reaction is high

  • If blood test is negative, and suspicion of allergic reaction is high

  • if immunotherapy is needed, skin test must precede beginning treatment



most sensitive method

  • most sensitive method

  • Venoms are standardized based on Hyaluronidase content : Honeybee, Yellow Jacket, Yellow Hornet, Bald-faced Hornet, Polistes Wasps

  • Bumblebee venom available only in Europe





Recommended Testing Sequence :

  • Recommended Testing Sequence :

    • first do In Vitro tests
    • then EXACTLY follow instructions in venom package insert
    • single prick test at 1g/ml to screen for extreme sensitivity
    • prepare 1:10 dilutions (1ng/ml to 1g/ml)
    • do IDT with 1:10 dilutions until first positive wheal.
    • DO NOT USE confirming wheal


Insect Avoidance

  • Insect Avoidance

    • Caution during outdoor activities
      • Look for nests on ground, roofs
    • Extra care in Picnic areas
      • Orchards, trash containers, soda cans, fruit
    • Wear shoes, long sleeves, pants, gloves
    • Avoid fragrances, bright colors
    • Use protective suit, veil, & gloves when working with bees


Epinephrine kits

  • Epinephrine kits

    • Kits must be with you to be useful
      • epinephrine stability is poor with oxygen, light, & heat ( replace kits as needed )
    • Practice epinephrine use
    • Always call 911 after epinephrine
  • Antihistamines & corticosteroids are OK to use AFTER epinephrine



Venom Immunotherapy (Allergy Shots) - should be considered in all persons who:

  • Venom Immunotherapy (Allergy Shots) - should be considered in all persons who:

  • have a positive history of one or more Systemic Reactions to stings

  • have a positive diagnostic test

  • are likely to be re-stung



Only 25 - 50% of patients repeat Systemic Reactions when re-stung

  • Only 25 - 50% of patients repeat Systemic Reactions when re-stung

  • risk increases with repeat stings, especially if close together in time

  • higher risk for occupational exposure

  • higher risk for asthmatics

  • highest risk if Circulatory Shock occurs

  • clinical judgement required



Yellow Jacket sting often causes cross-reactions with both Hornet species

  • Yellow Jacket sting often causes cross-reactions with both Hornet species

  • If Yellow Jacket positively identified, treat with Yellow Jacket venom alone

  • If not positively identified, treat with Mixed Vespid venom (1:1:1 mix of Yellow Jacket, Yellow Hornet, Bald-faced Hornet)



Weak cross-reactions with Yellow Jackets & Hornets

  • Weak cross-reactions with Yellow Jackets & Hornets

  • If positive test, treat with Polistes Wasp venom (unless positive Yellow Jacket ID was made)



Honeybee venom may not completely protect, since bumblebee contains some unique antigens

  • Honeybee venom may not completely protect, since bumblebee contains some unique antigens

  • If minimally exposed to bumblebees, treat with honeybee venom

  • If employed where bumblebees are being used as pollenators, treat with bumblebee venom



Use available whole body extract. Switch to venom, when that becomes available

  • Use available whole body extract. Switch to venom, when that becomes available



Asian and Australian fire ants are distinct species, and require specific immunotherapy that is different from that for American fire ants (Solenopsis sp.)

  • Asian and Australian fire ants are distinct species, and require specific immunotherapy that is different from that for American fire ants (Solenopsis sp.)



Immunotherapy may prevent serum sickness



Immunotherapy Escalation

  • Immunotherapy Escalation

  • Schedules vary from slow buildup (weeks) to rapid (hours to days)

  • Rapid methods have higher risk of anaphylaxis

  • Use rapid method only when patient is very likely to be re-stung in near future

  • Use strict anaphylaxis precautions if doing rapid therapy



Modified Rapid Schedule

  • Modified Rapid Schedule

    • Day 1 0.1g, 1g, 3g, given every 20 min.
    • Week 2 10 g
    • Week 3 20 g
    • Week 4 40 g
    • Week 5 70 g
    • Week 6 100 g Maintenance dose
    • Continue weekly injections to 16 weeks, then continue monthly injections for 5 years


Up to 20% of patients are not protected by 100 g venom doses

  • Up to 20% of patients are not protected by 100 g venom doses

  • 150 - 400 g may be required in these patients

  • Mixed vespid therapy is 300 g; bee or single wasp therapy is more likely to need increase

  • Evaluate patients requiring large venom doses by serum tryptase for systemic mastocytosis

  • Rueff F, Wenderroth A, Przybilla B. Patients still reacting to a sting challenge while receiving conventional Hymenoptera venom immunotherapy are protected by increased venom doses. J Allergy Clin Immunol. 2001; 108:1027-32



Early IgE increase, peaks at 8-12 weeks

  • Early IgE increase, peaks at 8-12 weeks

  • Subsequent steady IgE decrease over years

  • Increasing IgG until 2-4 months

  • Subsequent plateau or slight decline

  • Skin & IgE tests may become negative



IgG > 3 g / ml, or else immunotherapy dose must be increased (to 200 g or more)

  • IgG > 3 g / ml, or else immunotherapy dose must be increased (to 200 g or more)

  • IgG > 5 g / ml is usually protective, but, some lower levels protect, and rarely, high levels do not



Treatment effectiveness is 97% (Wasps) or 80% (Honeybees)

  • Treatment effectiveness is 97% (Wasps) or 80% (Honeybees)

  • About 20% have mild reactions due to treatment, usually early in therapy

  • Rare patients (0.7 %) require epinephrine during therapy











IgG and IgE can be measured in blood.

  • IgG and IgE can be measured in blood.

  • If protective immunity is occurring:

  • Higher venom doses can be used if standard doses do not work







After 5 years, before stopping maintenance injections, measure blood IgE and IgG

  • After 5 years, before stopping maintenance injections, measure blood IgE and IgG

    • IgE should drop to 0
    • IgG should be > 5 g / ml
  • How likely is this person to be restung ?

  • How severe was the last sting reaction ?

  • Are there any treatment side effects ?

  • Weigh the pros and cons carefully



Whole body fire ant immunotherapy is effective (2% reactions when stung, vs 100% in non-immunized patients)

  • Whole body fire ant immunotherapy is effective (2% reactions when stung, vs 100% in non-immunized patients)

  • But, standard fire ant immunotherapy takes months, during which time re-sting may occur

  • Alternately, a rush schedule, over 2 days, had only a 5.2% anaphylaxis rate, and should be considered for patients at high risk of re-sting



High risk persons may not be able to stop

  • High risk persons may not be able to stop

    • + anaphylactic shock
    • + systemic reactions to venom therapy
    • + occupational exposure
    • + Honeybee sensitive
    • + Systemic mastocytosis
  • Avg. 10% risk after 5 years Rx (8-16%)



Avoidance techniques should always be employed

  • Avoidance techniques should always be employed

  • Emergency epinephrine should always be with you

  • Accurate diagnosis is critical

  • Immunotherapy is highly effective, but treatment failures still can occur








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