Allergy Asthma Immunol Res.  2013 May;5(3):129-137. 10.4168/aair.2013.5.3.129.

Management of Insect Sting Hypersensitivity: An Update

Affiliations
  • 1Division of Allergy and Immunology, Arkansas Children's Hospital, Little Rock, AR, USA. robbiepesek@gmail.com
  • 2Division of Allergy and Immunology, University of South Florida and the James A. Haley Veterans' Hospital, Tampa, FL, USA.

Abstract

Reactions to Hymenoptera insect stings are common. While most are self-limited, some induce systemic allergic reactions or anaphylaxis. Prompt recognition, diagnosis, and treatment of these reactions are important for improving quality-of-life and reducing the risk of future sting reactions. This review summarizes the current recommendations to diagnose and treat Hymenoptera sting induced allergic reactions and highlights considerations for various populations throughout the world.

Keyword

Hymenoptera allergy; venom immunotherapy; sting-induced anaphylaxis; insect sting allergy; insect sting hypersensitivity

MeSH Terms

Anaphylaxis
Bites and Stings
Hymenoptera
Hypersensitivity
Insect Bites and Stings
Insects

Figure

  • Figure Taxonomy of Hymenoptera species.


Reference

1. Chafee FH. Insect sting allergy. J Allergy. 1969. 43:309.
2. Braun LIB. Notes on desensitization of a patient hypersensitive to bee stings. S Afr Med Rec. 1925. 23:408–409.
3. Guralnick MW, Benton AW. Levine MI, Lockey RF, editors. Entomological aspects of insect sting allergy. Monograph on insect allergy. 2003. 4th ed. Milwaukee: AAAAI;11–25.
4. Rhoades RB, Schafer WL, Newman M, Lockey R, Dozier RM, Wubbena PF, Townes AW, Schmid WH, Neder G, Brill T, Wittig HJ. Hypersensitivity to the imported fire ant in Florida. Report of 104 cases. J Fla Med Assoc. 1977. 64:247–254.
5. Lockey RF. Systemic reactions to stinging ants. J Allergy Clin Immunol. 1974. 54:132–146.
6. Antonicelli L, Bilò MB, Bonifazi F. Epidemiology of Hymenoptera allergy. Curr Opin Allergy Clin Immunol. 2002. 2:341–346.
7. Kemp SF, deShazo RD, Moffitt JE, Williams DF, Buhner WA 2nd. Expanding habitat of the imported fire ant (Solenopsis invicta): a public health concern. J Allergy Clin Immunol. 2000. 105:683–691.
8. Lockey RF, Turkeltaub PC, Baird-Warren IA, Olive CA, Olive ES, Peppe BC, Bukantz SC. The Hymenoptera venom study I, 1979-1982: demographics and history-sting data. J Allergy Clin Immunol. 1988. 82:370–381.
9. Golden DB, Marsh DG, Kagey-Sobotka A, Freidhoff L, Szklo M, Valentine MD, Lichtenstein LM. Epidemiology of insect venom sensitivity. JAMA. 1989. 262:240–244.
10. Incorvaia C, Mauro M, Pastorello EA. Hymenoptera stings in conscripts. Allergy. 1997. 52:680–681.
11. Golden DB. Insect sting anaphylaxis. Immunol Allergy Clin North Am. 2007. 27:261–272.
12. Fernandez J, Blanca M, Soriano V, Sanchez J, Juarez C. Epidemiological study of the prevalence of allergic reactions to Hymenoptera in a rural population in the Mediterranean area. Clin Exp Allergy. 1999. 29:1069–1074.
13. Biló BM, Rueff F, Mosbech H, Bonifazi F, Oude-Elberink JN. The EAACI Interest Group on Insect Venom Hypersensitivity. Diagnosis of Hymenoptera venom allergy. Allergy. 2005. 60:1339–1349.
14. Bilò BM, Bonifazi F. Epidemiology of insect-venom anaphylaxis. Curr Opin Allergy Clin Immunol. 2008. 8:330–337.
15. Clark S, Camargo CA Jr. Emergency treatment and prevention of insect-sting anaphylaxis. Curr Opin Allergy Clin Immunol. 2006. 6:279–283.
16. Pumphrey RS. Fatal anaphylaxis in the UK, 1992-2001. Novartis Found Symp. 2004. 257:116–128.
17. Low I, Stables S. Anaphylactic deaths in Auckland, New Zealand: a review of coronial autopsies from 1985 to 2005. Pathology. 2006. 38:328–332.
18. Simon MR, Mulla ZD. A population-based epidemiologic analysis of deaths from anaphylaxis in Florida. Allergy. 2008. 63:1077–1083.
19. Liew WK, Williamson E, Tang ML. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol. 2009. 123:434–442.
20. Fricker M, Helbling A, Schwartz L, Müller U. Hymenoptera sting anaphylaxis and urticaria pigmentosa: clinical findings and results of venom immunotherapy in ten patients. J Allergy Clin Immunol. 1997. 100:11–15.
21. Kosnik M. Anaphylaxis to venom without IgE antibody. Allergy. 2000. 55:676–677.
22. Ludolph-Hauser D, Ruëff F, Fries C, Schöpf P, Przybilla B. Constitutively raised serum concentrations of mast-cell tryptase and severe anaphylactic reactions to Hymenoptera stings. Lancet. 2001. 357:361–362.
23. Goldberg A, Confino-Cohen R. Timing of venom skin tests and IgE determinations after insect sting anaphylaxis. J Allergy Clin Immunol. 1997. 100:182–184.
24. Müller UR. Insect sting allergy: clinical picture, diagnosis, and treatment. 1990. Stuttgart: Gustav Fischer Verlag.
25. Georgitis JW, Reisman RE. Venom skin tests in insect-allergic and insect-nonallergic populations. J Allergy Clin Immunol. 1985. 76:803–807.
26. Lockey RF, Turkeltaub PC, Olive CA, Baird-Warren IA, Olive ES, Bukantz SC. The Hymenoptera venom study. II: Skin test results and safety of venom skin testing. J Allergy Clin Immunol. 1989. 84:967–974.
27. Tracy JM, Demain JG, Quinn JM, Hoffman DR, Goetz DW, Freeman TM. The natural history of exposure to the imported fire ant (Solenopsis invicta). J Allergy Clin Immunol. 1995. 95:824–828.
28. Hoffman DR, Dove DE, Moffitt JE, Stafford CT. Allergens in Hymenoptera venom. XXI. Cross-reactivity and multiple reactivity between fire ant venom and bee and wasp venoms. J Allergy Clin Immunol. 1988. 82:828–834.
29. Brown SG, Wiese MD, Blackman KE, Heddle RJ. Ant venom immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet. 2003. 361:1001–1006.
30. Golden DB, Kagey-Sobotka A, Norman PS, Hamilton RG, Lichtenstein LM. Insect sting allergy with negative venom skin test responses. J Allergy Clin Immunol. 2001. 107:897–901.
31. Kontou-Fili K. Patients with negative skin tests. Curr Opin Allergy Clin Immunol. 2002. 2:353–357.
32. Mittag D, Akkerdaas J, Ballmer-Weber BK, Vogel L, Wensing M, Becker WM, Koppelman SJ, Knulst AC, Helbling A, Hefle SL, Van Ree R, Vieths S. Ara h 8, a Bet v 1-homologous allergen from peanut, is a major allergen in patients with combined birch pollen and peanut allergy. J Allergy Clin Immunol. 2004. 114:1410–1417.
33. Shin YS, Liu JN, Hur GY, Hwang EK, Nam YH, Jin HJ, Lee SM, Ye YM, Nahm DH, Park HS. Clinical features and the diagnostic value of component allergen-specific IgE in Hymenoptera venom allergy. Allergy Asthma Immunol Res. 2012. 4:284–289.
34. de Graaf DC, Aerts M, Danneels E, Devreese B. Bee, wasp and ant venomics pave the way for a component-resolved diagnosis of sting allergy. J Proteomics. 2009. 72:145–154.
35. Parrino J, Kandawalla NM, Lockey RF. Treatment of local skin response to imported fire ant sting. South Med J. 1981. 74:1361–1364.
36. Westermann-Clark E, Fitzhugh DJ, Lockey RF. Increasing cost of epinephrine autoinjectors. J Allergy Clin Immunol. 2012. 130:822–823.
37. Hunt KJ, Valentine MD, Sobotka AK, Benton AW, Amodio FJ, Lichtenstein LM. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med. 1978. 299:157–161.
38. Müller U, Thurnheer U, Patrizzi R, Spiess J, Hoigné R. Immunotherapy in bee sting hypersensitivity. Bee venom versus wholebody extract. Allergy. 1979. 34:369–378.
39. Lockey RF, Turkeltaub PC, Olive ES, Hubbard JM, Baird-Warren IA, Bukantz SC. The Hymenoptera venom study. III: Safety of venom immunotherapy. J Allergy Clin Immunol. 1990. 86:775–780.
40. Lerch E, Müller UR. Long-term protection after stopping venom immunotherapy: results of re-stings in 200 patients. J Allergy Clin Immunol. 1998. 101:606–612.
41. Golden DB, Addison BI, Gadde J, Kagey-Sobotka A, Valentine MD, Lichtenstein LM. Prospective observations on stopping prolonged venom immunotherapy. J Allergy Clin Immunol. 1989. 84:162–167.
42. Keating MU, Kagey-Sobotka A, Hamilton RG, Yunginger JW. Clinical and immunologic follow-up of patients who stop venom immunotherapy. J Allergy Clin Immunol. 1991. 88:339–348.
43. Golden DB, Kwiterovich KA, Kagey-Sobotka A, Valentine MD, Lichtenstein LM. Discontinuing venom immunotherapy: outcome after five years. J Allergy Clin Immunol. 1996. 97:579–587.
44. Golden DB, Kwiterovich KA, Kagey-Sobotka A, Lichtenstein LM. Discontinuing venom immunotherapy: extended observations. J Allergy Clin Immunol. 1998. 101:298–305.
45. Nordvall SL, Johansson SG, Ledford DK, Lockey RF. Allergens of the imported fire ant. J Allergy Clin Immunol. 1988. 82:567–576.
46. Freeman TM, Hylander R, Ortiz A, Martin ME. Imported fire ant immunotherapy: effectiveness of whole body extracts. J Allergy Clin Immunol. 1992. 90:210–215.
47. Quinn JM, Tajiri KS, Motta P, Freeman TM. Long-term efficacy after discontinuation of imported fire ant (Solenopsis invicta) immunotherapy. J Allergy Clin Immunol. 1994. 93:S223.
48. Golden DB, Kagey-Sobotka A, Norman PS, Hamilton RG, Lichtenstein LM. Outcomes of allergy to insect stings in children, with and without venom immunotherapy. N Engl J Med. 2004. 351:668–674.
49. Golden DB. Insect allergy in children. Curr Opin Allergy Clin Immunol. 2006. 6:289–293.
50. Valentine MD, Schuberth KC, Kagey-Sobotka A, Graft DF, Kwiterovich KA, Szklo M, Lichtenstein LM. The value of immunotherapy with venom in children with allergy to insect stings. N Engl J Med. 1990. 323:1601–1603.
51. Schuberth KC, Kwiterovich KA, Kagey-Sobotka A, Lichtenstein LM, Valentine MD. Starting and stopping venom immunotherapy (VIT) in children with insect allergy. J Allergy Clin Immunol. 1988. 81:200.
52. Freeman TM. Clinical practice. Hypersensitivity to Hymenoptera stings. N Engl J Med. 2004. 351:1978–1984.
53. Schwartz HJ, Golden DB, Lockey RF. Venom immunotherapy in the Hymenoptera-allergic pregnant patient. J Allergy Clin Immunol. 1990. 85:709–712.
54. Golden DB, Kelly D, Hamilton RG, Craig TJ. Venom immunotherapy reduces large local reactions to insect stings. J Allergy Clin Immunol. 2009. 123:1371–1375.
55. Oude Elberink JN, van der Heide S, Guyatt GH, Dubois AE. Immunotherapy improves health-related quality of life of adult patients with dermal reactions following yellow jacket stings. Clin Exp Allergy. 2009. 39:883–889.
56. Bonadonna P, Perbellini O, Passalacqua G, Caruso B, Colarossi S, Dal Fior D, Castellani L, Bonetto C, Frattini F, Dama A, Martinelli G, Chilosi M, Senna G, Pizzolo G, Zanotti R. Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels. J Allergy Clin Immunol. 2009. 123:680–686.
57. González de Olano D, Alvarez-Twose I, Esteban-López MI, Sánchez-Muñoz L, de Durana MD, Vega A, García-Montero A, González-Mancebo E, Belver T, Herrero-Gil MD, Fernández-Rivas M, Orfao A, de la Hoz B, Castells MC, Escribano L. Safety and effectiveness of immunotherapy in patients with indolent systemic mastocytosis presenting with Hymenoptera venom anaphylaxis. J Allergy Clin Immunol. 2008. 121:519–526.
58. Niedoszytko M, de Monchy J, van Doormaal JJ, Jassem E, Oude Elberink JN. Mastocytosis and insect venom allergy: diagnosis, safety and efficacy of venom immunotherapy. Allergy. 2009. 64:1237–1245.
59. Bonadonna P, Zanotti R, Caruso B, Castellani L, Perbellini O, Colarossi S, Chilosi M, Dama A, Schiappoli M, Pizzolo G, Senna G, Passalacqua G. Allergen specific immunotherapy is safe and effective in patients with systemic mastocytosis and Hymenoptera allergy. J Allergy Clin Immunol. 2008. 121:256–257.
60. Oude Elberink JN, de Monchy JG, Kors JW, van Doormaal JJ, Dubois AE. Fatal anaphylaxis after a yellow jacket sting, despite venom immunotherapy, in two patients with mastocytosis. J Allergy Clin Immunol. 1997. 99:153–154.
61. Reisman RE, Müller UR, Wypych JI, Lazell MI. Studies of coexisting honeybee and vespid-venom sensitivity. J Allergy Clin Immunol. 1984. 73:246–252.
62. Reisman RE, Livingston A. Venom immunotherapy: 10 years of experience with administration of single venoms and 50 micrograms maintenance doses. J Allergy Clin Immunol. 1992. 89:1189–1195.
63. Valentine MD. Insect venom allergy: diagnosis and treatment. J Allergy Clin Immunol. 1984. 73:299–304.
64. Ruëff F, Wenderoth 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. 108:1027–1032.
65. Bousquet J, Ménardo JL, Velasquez G, Michel FB. Systemic reactions during maintenance immunotherapy with honey bee venom. Ann Allergy. 1988. 61:63–68.
66. Golden DB, Kagey-Sobotka A, Valentine MD, Lichtenstein LM. Prolonged maintenance interval in Hymenoptera venom immunotherapy. J Allergy Clin Immunol. 1981. 67:482–484.
67. Goldberg A, Confino-Cohen R. Maintenance venom immunotherapy administered at 3-month intervals is both safe and efficacious. J Allergy Clin Immunol. 2001. 107:902–906.
68. Moffitt JE, Golden DB, Reisman RE, Lee R, Nicklas R, Freeman T, deshazo R, Tracy J, Bernstein IL, Blessing-Moore J, Khan DA, Lang DM, Portnoy JM, Schuller DE, Spector SL, Tilles SA. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol. 2004. 114:869–886.
69. Bernstein JA, Kagen SL, Bernstein DI, Bernstein IL. Rapid venom immunotherapy is safe for routine use in the treatment of patients with Hymenoptera anaphylaxis. Ann Allergy. 1994. 73:423–428.
70. Birnbaum J, Charpin D, Vervloet D. Rapid Hymenoptera venom immunotherapy: comparative safety of three protocols. Clin Exp Allergy. 1993. 23:226–230.
71. Golden DB, Valentine MD, Kagey-Sobotka A, Lichtenstein LM. Regimens of Hymenoptera venom immunotherapy. Ann Intern Med. 1980. 92:620–624.
72. Schiavino D, Nucera E, Pollastrini E, De Pasquale T, Buonomo A, Bartolozzi F, Lombardo C, Roncallo C, Patriarca G. Specific ultrarush desensitization in Hymenoptera venom-allergic patients. Ann Allergy Asthma Immunol. 2004. 92:409–413.
73. Roll A, Hofbauer G, Ballmer-Weber BK, Schmid-Grendelmeier P. Safety of specific immunotherapy using a four-hour ultra-rush induction scheme in bee and wasp allergy. J Investig Allergol Clin Immunol. 2006. 16:79–85.
74. Steiss JO, Jödicke B, Lindemann H. A modified ultrarush insect venom immunotherapy protocol for children. Allergy Asthma Proc. 2006. 27:148–150.
75. Tankersley MS, Walker RL, Butler WK, Hagan LL, Napoli DC, Freeman TM. Safety and efficacy of an imported fire ant rush immunotherapy protocol with and without prophylactic treatment. J Allergy Clin Immunol. 2002. 109:556–562.
76. Golden DB, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D. Joint Task Force on Practice Parameters. American Academy of Allergy, Asthma & Immunology (AAAAI). American College of Allergy, Asthma & Immunology (ACAAI). Joint Council of Allergy, Asthma and Immunology. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol. 2011. 127:852–854.
77. Light WC. Insect sting fatality 9 years after venom treatment (venom allergy, fatality). J Allergy Clin Immunol. 2001. 107:925.
78. Reisman RE. Duration of venom immunotherapy: relationship to the severity of symptoms of initial insect sting anaphylaxis. J Allergy Clin Immunol. 1993. 92:831–836.
79. Golden DB. Discontinuing venom immunotherapy. Curr Opin Allergy Clin Immunol. 2001. 1:353–356.
80. Golden DB, Kagey-Sobotka A, Lichtenstein LM. Survey of patients after discontinuing venom immunotherapy. J Allergy Clin Immunol. 2000. 105:385–390.
Full Text Links
  • AAIR
Actions
Cited
CITED
export Copy
Close
Share
  • Twitter
  • Facebook
Similar articles
Copyright © 2024 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr