Acute coronary syndrome due to plaque erosion likely triggered by insect bites: a case series of Kounis syndrome

Background

Kounis syndrome is the concurrence of acute coronary syndrome (ACS), including coronary spasm, acute myocardial infarction, and stent thrombosis due to an allergic and/or anaphylactoid insult.

Case summary

We present two cases of Kounis syndrome likely triggered by insect bites, with plaque erosion demonstrated using optical coherence tomography (OCT). Three common findings were derived from this case series. First, the patients developed a rash after an insect bite followed by ACS. Second, immunoglobulin E levels were increased. Finally, OCT identified the aetiology of ACS in this case series as erosion of the culprit lesions.

Discussion

Kounis syndrome, which is ACS following allergic reactions due to insect bites, is a rare complication. Kounis syndrome is probably not uncommon, but underdiagnosed. It is important for physicians to consider the treatment of Kounis syndrome in the complex course of ACS associated with allergic reactions. Furthermore, patients with a history of Kounis syndrome should avoid antigen exposure during secondary prophylaxis. In some cases, it may take several days from antigen exposure to the onset of ACS. Considering Kounis syndrome is beneficial for early diagnosis and appropriate treatment.

Cross-Reactive Carbohydrate Determinant in Apis mellifera, Solenopsis invicta and Polybia paulista Venoms: Identification of Allergic Sensitization and Cross-Reactivity

Allergic reactions to Hymenoptera venom, which could lead to systemic and even fatal symptoms, is characterized by hypersensitivity reactions mediated by specific IgE (sIgE) driven to venom allergens. Patients multisensitized to sIgE usually recognize more than one allergen in different Hymenoptera species. However, the presence of sIgE directed against Cross-Reactive Carbohydrate Determinant (CCD), which occurs in some allergens from Hymenoptera venom, hampers the identification of the culprit insects. CCD is also present in plants, pollen, fruits, but not in mammals. Bromelain (Brl) extracted from pineapples is a glycoprotein commonly used for reference to sIgE-CCD detection and analysis. In sera of fifty-one Hymenoptera allergic patients with specific IgE ≥ 1.0 KU/L, we assessed by immunoblotting the reactivity of sIgE to the major allergens of Apis mellifera, Polybia paulista and Solenopsis invicta venoms. We also distinguished, using sera adsorption procedures, the cases of CCD cross-reaction using Brl as a marker and inhibitor of CCD epitopes. The presence of reactivity for bromelain (24–28 kDa) was obtained in 43% of the patients, in which 64% presented reactivity for more than one Hymenoptera venom in radioallergosorbent (RAST) tests, and 90% showed reactivity in immunoblot analysis to the major allergens of Apis mellifera, Polybia paulista and Solenopsis invicta venoms. Sera adsorption procedures with Brl lead to a significant reduction in patients’ sera reactivity to the Hymenoptera allergens. Immunoblotting assay using pre- and post-Brl adsorption sera from wasp-allergic patients blotted with non-glycosylated recombinant antigens (rPoly p1, rPoly p5) from Polybia paulista wasp venom showed no change in reactivity pattern of sIgE that recognize allergen peptide epitopes. Our results, using Brl as a marker and CCD inhibitor to test sIgE reactivity, suggest that it could complement diagnostic methods and help to differentiate specific reactivity to allergens’ peptide epitopes from cross-reactivity caused by CCD, which is extremely useful in clinical practice.

Relationship between Some Environmental and Climatic Factors on Outbreak of Whiteflies, the Human Annoying Insects

Background

The reports of numerous outbreaks of whiteflies from different parts of the world have increased its medical importance. The aim of this study was to determine relationship between environmental changes and climatic factors with the outbreak of the whitefly population in Tehran, the capital of Iran.

Methods

This study was carried out in urban areas of Tehran, where the increasing population of whiteflies was reported frequently during 2018. In order to entrap the whiteflies, 20 yellow sticky cards smeared with white refined grease were installed on the trunks of the trees at twice per month as trapping time intervals. The captured flies were transferred and conserved in cans containing 70% alcohol and were counted accurately under a stereomicroscope. To determine the relationship between air quality index, precipitation, air temperature and air humidity as environmental and climatic factors with the abundance of whiteflies, change point analysis and Generalized Estimating Equations (GEE) was used.

Results

The most density of white flies per trap was 256.6 and 155.6 in early October and late September respectively. The number moved closer to zero from November to April. The population of whiteflies was inversely correlated with the level of air quality index (p= 0.99) and precipitation (p= 0.95), and it had a direct correlation with the high temperature. Also, the population of whiteflies had a direct correlation with the level of air humidity in the first half of the year.

Conclusion

According to these findings, during spring and summer from early May to early October.

Acute Pancreatitis and Rhabdomyolysis with Acute Kidney Injury following Multiple Wasp Stings

Multiple wasp stings can induce multiple organ dysfunction by toxic reactions. However, acute pancreatitis is a rare manifestation in wasp sting injury. A 74-year-old woman visited the emergency department by anaphylactic shock because of multiple wasp stings. Acute kidney injury, rhabdomyolysis, hepatotoxicity, and coagulopathy were developed next day. Serum amylase and lipase were elevated and an abdominal computed tomography revealed an acute pancreatitis. Urine output was recovered after 16 days of oliguria (below 500 ml/day). Her kidney, liver, and pancreas injury gradually improved after sessions of renal replacement therapy.

Terrestrial Arthropods as a Public Health Issue in South–Eastern Romania

Little is known about the prevalence and severity of allergic reactions caused by terrestrial arthropods in Romania although bites and stings of arthropods represent a widely recognized public health issue. We conducted a retrospective study in Constanța, the largest city at the Romanian Black Sea coast, and documented 207 cases during 2013–2014, representing 0.5% of the total number of records at the Emergency Department of the County Clinical Emergency Hospital. Young men and women presented themselves more often to the hospital to report this type of injuries and most arthropods causing allergic reactions were not identified. Our study brings novel information on the prevalence of injuries inflicted by terrestrial arthropods on the human adult population at the Romanian Black Sea coast, it highlights existing knowledge gaps and provides information on which to base future guidelines.

Insect Consumption to Address Undernutrition, a National Survey on the Prevalence of Insect Consumption among Adults and Vendors in Laos

Background

Insect consumption (entomophagy) is a potentially high nutritious and healthy source of food with high fat, protein, vitamin, fiber and micronutrient content. At least 2 billion people globally eat insects (over 1900 edible species) though this habit is regarded negatively by others. There is a limited amount of data on the perception and consumption of insects. We conducted a national cross-sectional survey in the Lao People’s Democratic Republic (Laos) to assess the prevalence and characteristics of insect consumption among adult lay people and insect vendors.

Methods

We conducted a multi stage randomized national survey in 1303 households in 96 villages in 16 Lao provinces. Three insect vendors or collectors per village were also included. A standardized pretested questionnaire addressed the following issues: socioeconomic characteristics, type of insects consumed and frequency of consumption, reasons and trends in consumption as well as reports on side effects, over the last 10 years.

Results

A total of 1059 adults (Sex ratio F/M: 1.2, 30 ethnic groups), and 256 vendors were enrolled. A total of 1025 (96.8%) lay people were currently insect consumers, 135 (13.0%) daily or weekly consumers, and 322 (31.1%) consumed several times per month. For the majority (575, 55.6%) the consumption was infrequent (less than a few times per year) and only 22 (2%) had never eaten insects. Consumption started in childhood. Insect availability was seasonal (670, 63.2%) and respondents would have eaten more insects, if they had been more available (919, 86.7%). Hmong and Leu ethnic groups had significantly lower consumption levels than the general population. Eggs of weaver ants, short-tailed crickets, crickets, grasshoppers, and cicadas were the top 5 insects consumed. Consumption had decreased in the last decade, mostly due to less availability (869; 84.0%) and change of life (29; 5.5%). Of 1059, 80 (7.5%) reported allergy problems and 106 (10.0%) reported some use in traditional medicine. A total of 874 (82.6%) were regular collectors.

Insect vendors (Sex ratio F/M: 5.3) were also collectors (185; 72.2%). They dedicated a mean time of 4.7 hours during the last harvesting period. The majority sold insects at markets (141, 55.0%). They had earned, on average, USD 6.0 the day before. Five insects (weaver ant eggs; bamboo worms; short-tailed crickets; crickets; wasps) represented 85% of the market.

Conclusion

Entomophagy is general in Laos, and well accepted despite a decreasing trend in consumption over the last decade. Its contribution to the Lao diet is limited to a minority of frequent consumers. Income through insect sales benefits mostly women. Consumption varies according to ethnicity, residence and season. Development of insect farming is still at an early stage. It could however increase availability of insects and contribute to the generation of income.

Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases

Background

Massive wasp stings have been greatly underestimated and have not been systematically studied. The aim of this study was to identify the clinical features and treatment strategies of severe wasp stings.

Methods and Findings

A multicenter retrospective study was undertaken in 35 hospitals and medical centers including 12 tertiary care hospitals and 23 secondary care hospitals in the Hubei Province, China. The detailed clinical data of 1091 hospitalized wasp sting patients were investigated. Over three-fourths (76.9%) of the cases had 10 or more stings and the in-hospital mortality of patients was 5.1%. Forty-eight patients died of organ injury following toxic reactions to the stings, whereas six died from anaphylactic shock. The in-hospital mortality in patients with >10 stings was higher than that of ≤10 stings (5.2% vs. 1.0%, p = 0.02). Acute kidney injury (AKI) was seen in 21.0% patients and most patients required blood purification therapy. Rhabdomyolysis was seen in 24.1% patients, hemolysis in 19.2% patients, liver injury in 30.1% patients, and coagulopathy in 22.5% patients. Regression analysis revealed that high creatinine level, shock, oliguria, and anemia were risk factors for death. Blood purification therapy was beneficial for patients with ≥20 stings and delayed hospital admission of patients (≥4 hours after sting).

Conclusions

In China, most patients with multiple wasp stings presented with toxic reactions and multiple organ dysfunction caused by the venom rather than an anaphylactic reaction. AKI is the prominent clinical manifestation of wasp stings with toxic reaction. High creatinine levels, shock, oliguria, and anemia were risk factors for death.

Insect anaphylaxis: where are we? The stinging facts 2012

PURPOSE OF REVIEW

Insect allergy remains an important cause of morbidity and mortality in the United States. In 2011, the third iteration of the stinging insect hypersensitivity practice parameter was published, the first being published in 1999 and the second in 2004. Since the 2004 edition, our understanding of insect hypersensitivity has continued to expand and has been incorporated into the 2011 edition. This work will review the relevant changes in the management of insect hypersensitivity occurring since 2004 and present our current understanding of the insect hypersensitivity diagnosis and management.

RECENT FINDINGS

Since the 2004 commissioning by the Joint Task Force (JTF) on Practice Parameters of 'Stinging insect hypersensitivity: a practice parameter update', there have been important contributions to our understanding of insect allergy. These contributions were incorporated into the 2011 iteration. Similar efforts were made by the European Allergy Asthma and Clinical Immunology Interest Group in 2005 and most recently in 2011 by the British Society of Allergy and Clinical Immunology.

SUMMARY

Our understanding of insect allergy, including the natural history, epidemiology, diagnostic testing, and risk factors, has greatly expanded. This evolution of knowledge should provide improved long-term management of stinging insect hypersensitivity. This review will focus primarily on the changes between the 2004 and 2011 stinging insect practice parameter commissioned by the JTF on Practice Parameters, but will, where appropriate, highlight the differences between working groups.

The use of concentrated heat after insect bites/stings as an alternative to reduce swelling, pain, and pruritus: an open cohort-study at German beaches and bathing-lakes

Background

Swelling, pain, and pruritus are the most relevant symptoms after insect bites/stings. Glucocorticoids and antihistamines are well established in insect sting treatment. Bite Away^® is a CE-certified medical device of class 2A (noninvasive device intended for administration to the body, which exchanges energy with the patient in a therapeutic manner) to reduce swelling, pruritus, and pain after insect bites/stings via non-invasive administration of concentrated heat to the skin. We therefore performed a prospective, non-interventional, single-arm cohort study with 146 volunteers using the visual analog scale (VAS) for insect bites/stings to study the reduction of swelling, pruritus, and pain. Demographic data, time from insect sting to treatment, number and duration of administrations of concentrated heat, relevant symptoms, and the development of a VAS score of swelling, pruritus, and pain on baseline, after 2, 5, and 10 minutes after administration, were registered.

Results

In total 146 subjects with a mean age of 29.4 ± 20.7 years (range 2–81) were enrolled in the study. Ninety-three (63.7%) of the subjects were stung by wasps, 33 (22.6%) of the subjects were bitten by mosquitoes, and eight suffered bee stings (5.3%). VAS score swelling decreased with statistical significance after the use of Bite Away^® from 4 before treatment to 2 and 1 after 2–5 and 10 minutes, respectively. VAS pain score was 6 before treatment, 2 after 2 minutes, 1 after 5 minutes, and 0 after 10 minutes (median). VAS pruritus score was only available for 52 (35.2%) of the patients. The score decreased from 5 before treatment, to 2 after 2 minutes, and 0 after 5 and 10 minutes.

Conclusions

Locally administrated concentrated heat leads to fast amelioration of symptoms. Usually an absence of symptoms is noticeable 10 minutes after administration. Pain reduction is the dominant effect. Compared with alternatives of pruritus and pain treatment after insect bites/stings, Bite Away^® seems to be the fastest treatment option available.