Stinging insect hypersensitivity: a practice parameter update 2011

Imported fire ant immunotherapy

Imported fire ants (IFAs) permeate many areas of the United States. The IFA allergy is a significant health problem for children and adults. Stings from IFAs cause pustules, localized reactions, and anaphylaxis. There have been at least 32 deaths attributed to IFA stings. Because of the difficulty with the extraction of venom from the fire ants, whole body extracts are the only commercially available serum for immunotherapy. Fortunately, whole body extract immunotherapy given conventionally or through the rush method has proven to be efficacious and safe. It is recommended for the treatment of IFA hypersensitivity. Maintenance immunotherapy is typically given at 4-week intervals. However, more recent research has revealed that these intervals can gradually be extended up to 12 weeks similar to flying Hymenoptera venom immunotherapy. Long-term adherence to IFA immunotherapy remains an obstacle for many patients despite its potential as a life-saving treatment.

Safety and Efficacy of VIT against Wasp Venom in Ultra-Rush Protocols in Patients Older Than 60 Years

BACKGROUND

Allergen immunotherapy remains a widely recognized and widely used method for the treatment of selected allergic diseases. Currently, according to the European Academy Of Allergy and Clinical Immunology (EAACI) guidelines, venom immunotherapy (VIT) may be considered for patients over 60. Nevertheless, no separate studies have confirmed the efficacy and safety of this therapy. This study aimed to evaluate the short-term effectiveness of VIT against wasp allergens in an ultra-rush protocol for older patients compared to young patients.

METHODS

Among the 113 patients included in this study, 51 were older than 60 years (Group A), and 62 formed the control "young group" (age range: 18-35 years). All patients were desensitized to wasp venom using the ultra-rush protocol according to Muller and aqueous solutions of vaccines containing wasp venom. A basophil activation test (Basotest, Orpegen Pharma, Germany) and intracutaneous tests with dilutions of wasp allergen and specific IgE to extract wasp venom were performed at the start and after six months of VIT. The safety of VIT was assessed on the basis of the international Mueller scale.

RESULTS

One hundred and eleven patients with confirmed wasp allergies completed six months of VIT: 51 participants over 60 years of age (Group A) and 60 young people (Group B). No systemic adverse reactions were observed during the VIT induction phase. However, large local reactions were noted in 17% of older patients and 20% of young patients at a similar level (p > 0.05). During maintenance VIT, two mild grade I systemic reactions were confirmed in young patients. These symptoms resolved spontaneously. There were no such reactions in older patients. The effectiveness of VIT was tested using BAT. There was a statistically significant reduction in CD63 reactivity in 86% of patients in Group A, and a comparable and substantial decrease in 84% of young patients in Group B. According to the BAT test, the mean reductions in the area under the curve (AUC) after six months of VIT were significant (p < 0.05) and comparable between Groups A and B: -6.52 vs. 7.21.

CONCLUSIONS

VIT against wasp venom is safe and effective in short-term observation, and is comparable to that used for young patients.

Long-term adherence to imported fire ant subcutaneous immunotherapy

BACKGROUND

Imported fire ant (IFA) whole-body extract subcutaneous immunotherapy (IT) is a safe and effective treatment for IFA hypersensitivity, with a recommended length of treatment of 3 to 5 years.

OBJECTIVE

To evaluate long-term IFA IT adherence in patients with IFA allergy living in an endemic area.

METHODS

During 2007 to 2014, patients with IFA-sting systemic reactions and a recommendation to start IFA IT were prospectively enrolled in this study. Subjects were contacted annually for interval IT adherence. Institutional review board approval was obtained.

RESULTS

A total of 87 subjects, ages 2 to 64 years, with a recommendation to initiate IFA IT, were enrolled. Subjects were predominantly adult (76%) and female (55%), and 30% had asthma. Of these patients, 77 (89%) initiated treatment within 1 year of recommendation; 18 (23%) adhered to a 3-year course; and 10 (13%) adhered to a 5-year course. At 3 years, there were no significant differences in adherence between male and female subjects (28% vs 19%, P = .33), children and adults (25% vs 22%, P = .79), or those with or without asthma (30% vs 20%, P = .31). Adherence in subjects with mild initial reactions was lower than in subjects with moderate-to-severe reactions (0% vs 25%, P = .05) at 3 years only. Conventional buildup and concurrent flying Hymenoptera venom immunotherapy were predictive of adherence. Reasons for discontinuation were relocation to a nonendemic area (29%) and inconvenience (27%).

CONCLUSION

This study showed poor long-term adherence to IFA IT at 3 and 5 years. Initial sting severity, buildup protocol, and concurrent flying Hymenoptera venom immunotherapy were predictors for long-term IT adherence.

An Action Design Research to Facilitate the Adoption of Personal Health Records

Adoption and user perceptions are dominant on personal health records literature and have led to a better understanding of what individuals' behaviors and perceptions are about the adoption of personal health records. However, these insights are descriptive and are not actionable to allow creating personal health records that will overcome the adoption problems identified by users. This study uses action design research to provide actionable knowledge regarding user perceptions and adoption and their application in the case of the digital allergy card. To achieve this, we conducted interviews with patients and physicians as part of the evaluation of the digital allergy card mock-up and the first prototype. As results, we provided some research proposals regarding the benefits of, levers for, and barriers to adoption of the digital allergy card that can be tested for several other personal health records.

[Diagnostic and therapeutic approach to anaphylaxis in childhood and adolescence]

Anaphylaxis is a suddenly occurring potentially life-threatening systemic allergic reaction. In childhood, food allergens play a major role but insect stings and drugs are also potential triggers. The symptoms appear in minutes up to few hours on the skin, airways, gastrointestinal tract and/or the cardiovascular system. Intramuscular adrenaline is the drug of first choice due to its rapid effectiveness and its low side effect potential. A detailed patient history and the determination of potential IgE antibodies must be carried out to identify the triggers. The register for anaphylaxis has improved knowledge on epidemiology. An education in anaphylaxis is useful for every patient as well as parents and caregivers. Allergen-specific immunotherapy is currently the only causal treatment option; however, at the present time it is only available for insect bites and peanut allergy.

Hypersensitivity to mosquito bites: A versatile Epstein-Barr virus disease with allergy, inflammation, and malignancy

Hypersensitivity to mosquito bites (HMB) is a rare disease characterized by transient intense skin reaction and systemic inflammation. Clinical presentation of HMB resembles other mosquito allergic responses, and it can also be difficult to clinically distinguish HMB from other severe allergic reactions. However, a distinctive pathophysiology underlies HMB. HMB belongs to a category of Epstein-Barr virus (EBV)-associated natural killer (NK) cell lymphoproliferative disorders (LPD). Hence, HMB may progress to systemic diseases, such as hemophagocytic lymphohistiocytosis, chronic active EBV disease, and EBV-associated malignancies. A triad of elevated serum IgE, NK lymphocytosis, and detection of EBV DNA in peripheral blood is commonly observed, and identification of EBV-infected NK cells usually facilitates the diagnosis. However, the effective treatment is limited, and its precise etiology remains unknown. Local CD4+ T cell proliferation triggered by mosquito bites appears to help induce EBV reactivation and EBV-infected NK-cell proliferation. These immunological interactions may explain the transient HMB signs and symptoms and the disease progression toward malignant LPD. Further research to elucidate the mechanism of HMB is warranted for better diagnosis and treatment of HMB and other forms of EBV-associated LPD.

Combining Discordant Serum IgE and Skin Testing Improves Diagnostic and Therapeutic Accuracy for Hymenoptera Venom Hypersensitivity Immunotherapy

BACKGROUND

Diagnosis of patients with hymenoptera venom hypersensitivity consists of elucidating clinical symptoms suggestive of systemic reaction (SR) and then confirmation of sensitization via intradermal skin testing (IDST) first and serum IgE assays such as ImmunoCAP (ICAP) as a complementary modality of diagnosis.

OBJECTIVE

Determine the concordance between ICAP and IDST in patients with a clinical history suggestive of hymenoptera venom SR. Determine whether venom immunotherapy would change on the basis of IDST versus ICAP results.

METHODS

A prospective diagnostic study was designed to test the concordance between IDST and ICAP venom testing in the diagnosis of hymenoptera venom hypersensitivity. This study entailed testing both IDST and ICAP for 5 hymenoptera venoms (honey bee, wasp, yellow jacket, yellow hornet, and white-faced hornet) in both a case group with SR to hymenoptera venom (N = 70) and a control group without SR (N = 51).

RESULTS

Significant discordance was observed between positive IDST and ICAP results for any of the 5 hymenoptera venoms (McNemar test, P = .001). In the case group, there was significant discordance for wasp (P < .0001), yellow jacket (P = .002), and white-faced hornet (P = .02). More than 47% of the case patients would have different venom immunotherapy prescriptions if ICAP and IDST had been performed during initial diagnosis versus IDST alone.

CONCLUSIONS

Our study shows significant discordance between IDST and ICAP; however, they are complementary. On the basis of our data, we propose ICAP testing first followed by IDST for ICAP-negative venoms as an alternative and efficient diagnostic strategy.

Pregnancy and Hymenoptera venom allergy

PURPOSE OF REVIEW

To evaluate the indication to perform venom immunotherapy (VIT) during pregnancy considering the risks of adverse events during the build-up phase or the maintenance phase and analyzing specific articles and guidelines on VIT.

RECENT FINDINGS

Only few studies treat this argument and literature only counts one recent study on the topic, whereas recent guidelines state the behavior to keep in pregnancy.

SUMMARY

Hymenoptera venom allergy (HVA) affects about 7.5% of the European population. VIT is the only effective disease-modifying treatment for patients presenting anaphylactic reactions. VIT counts several mechanisms of action, with the increase of IgG1 and IgG4 and a cytokine impairment inducing a Th2-Th1 shift. Pregnancy is a health condition where a Th2 profile is required to prevent fetal rejection, so VIT could be a problem for the fetus when started during pregnancy.

Parvovirus Infection in a Child Presenting with Erythema Multiforme and Vasculitis after a Yellow Jacket Bee Sting

Parvovirus B19 has a wide spectrum of clinical manifestations. Erythema multiforme and vasculitis are rarely reported with parvovirus B19 infections. Reactions to insect stings can range from local swelling to life-threatening systemic reactions. There have been rare reports of unusual reactions, such as vasculitis, occurring in a temporal relationship with insect stings. We report an 8-year-old patient having Parvovirus B-19-related erythema multiforme and vasculitis after a yellow jacket bee sting.

Prevalence of mastocytosis and hymenoptera venom allergy in the United States

BACKGROUND

Mastocytosis is a risk factor for hymenoptera venom anaphylaxis (HVA). Current guidelines recommend measuring tryptase in patients with HVA and that those with mastocytosis pursue lifelong venom immunotherapy (VIT). Available data on HVA and mastocytosis largely derive from European single-center studies, and the prevalence of HVA with and without mastocytosis in the United States is unknown.

OBJECTIVE

We sought to determine the prevalence of HVA and mastocytosis in the United States using an insurance claims database and evaluate the impact of mastocytosis on VIT in patients with HVA in a US cohort.

METHODS

The IBM Watson Database, consisting of insurance claims from approximately 27 million US patients in 2018, was queried to identify patients with HVA and/or mastocytosis. Furthermore, a retrospective study of 161 patients undergoing VIT between 2015 and 2018 at the University of Michigan was conducted.

RESULTS

In the IBM Watson Database, the prevalence of HVA was 167 per 100,000 (0.167%) and the prevalence of mastocytosis 10 per 100,000 (0.010%) overall and 97 per 100,000 (0.097%) among those with HVA. Mastocytosis showed a 9.7-fold increase among patients with HVA versus the general population. In the U-M cohort, 2.6% of patients with VIT had mastocytosis. Tryptase level did not correlate with venom reaction severity but was higher in patients with systemic VIT reactions.

CONCLUSIONS

We observed a lower US HVA prevalence than previously reported. Mastocytosis was more common in US patients with HVA, though at lower rates than previously reported. In patients with VIT there was no correlation between tryptase level and reaction severity.

Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes

Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.

Summer Buzz: All You Need to Know about Insect Sting Allergies

Insect stings can generate a range of immune and clinical reactions. Most reactions are local and self-limiting. Allergic reactions to insect stings can occur at all ages, with or without previous stings. Individuals with a history of anaphylaxis carry a significant risk of life-threatening anaphylaxis with future stings. Health-care providers are often unaware of the tremendous clinical benefits of venom immunotherapy for these select patients. Scientific knowledge about the natural history, risk factors, and optimal therapy for insect sting allergies has improved considerably in recent years.

Imported fire ant immunotherapy prescribing patterns in a large health care system during an 11-year period

BACKGROUND

The first large-scale evaluation of prescribing patterns for imported fire ant (IFA) in a large US health care system was published by Haymore et al in 2009. In this first evaluation of prescriptions from 1990 to 2007, the most often prescribed maintenance IFA prescription was 0.5 mL of 1:200 wt/vol.

OBJECTIVE

To provide an updated description of IFA prescribing patterns over the ensuing 11 years from same large health care system.

METHODS

We reviewed 1349 new IFA prescriptions written from 2007 to 2018, from a large nationwide health care system, with primary end points being maintenance prescription strength and prescribing patterns.

RESULTS

In comparison to the data published by Haymore et al in 2009, which reported that 17% of the prescriptions were written for 0.5 mL of 1:100 wt/vol maintenance, we found that 69% (95% CI: 66.4%-71.4%) of IFA prescriptions written in the past 11 years were for the maintenance concentration of 0.5 mL of 1:100 wt/vol. We further studied the linear trend over time of percentage of prescriptions written for individual concentrations and observed that the percentage of 1:100 wt/vol prescriptions increased 3.5% yearly (R² = 0.68, P < .001) from 2007 (40.0%, 95% CI: 24.6%-57.7%) to 2018 (84.4%, 95% CI: 77.4%-89.5%).

CONCLUSION

Our study shows significant improvement in the accuracy and precision of IFA immunotherapy dosing for patients with IFA hypersensitivity, with ascendancy of 0.5 mL 1:100 wt/vol as the predominant treatment dose. A total of 87% of patients within our study were treated within the parameter recommendations, a stark improvement from findings in the 2009 Haymore study.

Clinical Characteristics of Allergy to Hymenoptera Stings

OBJECTIVE

The purpose of this study was to evaluate the clinical characteristics of allergy to stings from the Hymenoptera order of insects in a hospital in Thailand.

METHODS

A descriptive retrospective analytical study was carried out in inpatients and outpatients suffering from Hymenoptera stings from 2009 to 2013 in Siriraj Hospital.

RESULTS

Medical records of 386 patients with an allergy to Hymenoptera stings were evaluated. Anaphylaxis was more common in patients younger than 15 years, who comprised 22.3% of patients in this study. The most common sting type was from wasps (58.3%). Eighty-five percent of patients sought medical treatment less than 24 hours after being stung. A systemic reaction and anaphylaxis were found in 9.9% and 4.4% of subjects, respectively. In 17 patients with anaphylaxis, only 11 patients (64.7%) received an epinephrine (adrenaline) injection as treatment, and only 8 (47.1%) received epinephrine autoinjectors or epinephrine-prefilled syringes to prevent a possible subsequent severe reaction. Significantly more patients younger than 15 years received epinephrine for prevention of an allergic reaction than did those older than 15 years (87.5% vs 11.7%, P < 0.001). Antibiotics were given to 43.0% of patients.

CONCLUSIONS

Anaphylaxis from Hymenoptera stings was more common in children than in adults. Only half of the patients visited the emergency room within 1 hour of being stung. Overuse of antibiotics and underuse of epinephrine were found. More information about Hymenoptera stings should be provided to the public, and the use of epinephrine should be encouraged in the case of severe reactions and anaphylaxis.

Usability and preference of epinephrine auto-injectors: Auvi-Q and EpiPen Jr

BACKGROUND

Despite the importance of prompt epinephrine auto-injector (EAI) treatment during anaphylaxis, proper administration technique is often lacking among patients and caregivers.

OBJECTIVE

To compare usability and participant preference of Auvi-Q and EpiPen Jr EAIs in a simulated life-threatening allergic emergency-use scenario.

METHODS

In this randomized, crossover, human-factors usability study, untrained adults (18-65 years) were tasked with using 0.15 mg Auvi-Q and EpiPen Jr trainers to simulate epinephrine administration to a child-sized manikin. Only written instructions on the device label and/or device voice instructions were available to participants. Endpoints included completing injection tasks per device instructions (primary endpoint), completing key injection tasks, and participant preference/ratings of devices. Completion of injection tasks were evaluated using a McNemar test for paired dichotomous data.

RESULTS

Ninety-six adults were included in study analyses. Significantly more participants completed all injection tasks per device instructions with Auvi-Q (85.4%) vs EpiPen Jr (19.8%; P < .001). Significant differences were also observed for completion of key injection tasks (Auvi -Q, 94.8%; EpiPen Jr, 72.9%; P < .001). No digital/hand injection errors were seen with Auvi-Q, whereas 14 participants (14.6%) would have accidentally received a digital/hand injection with EpiPen Jr (P < .001). Overall, significantly more participants preferred Auvi-Q over EpiPen Jr (91.7% vs 6.3%; P < .001 [2.1% no preference]). Median scores for 8 EAI characteristics were also higher for Auvi-Q vs EpiPen Jr.

CONCLUSION

In this study, untrained adults preferred and were more likely to use Auvi-Q correctly vs EpiPen Jr, highlighting the importance of device design for successful epinephrine administration during a life-threatening allergic emergency.

Venom allergy treatment practices in Poland in comparison to guidelines: next edition of the national audit

INTRODUCTION

Venom immunotherapy treatment (VIT) is the only causal treatment of hymenoptera venom anaphylaxis, which aims to provide long-lasting immunoprotection against severe reactions to subsequent stings.

AIM

To reassess the compliance of VIT procedures in the Polish allergy centres with the European guidelines.

MATERIAL AND METHODS

A structured questionnaire survey conducted in all 33 VIT-centres. The response rate was 94%.

RESULTS

The ultrarush initial protocol was the most common protocol (71%, n = 22), usually lasting for 3.5 h (50%, n = 7). The most frequent (36%, n = 11) time interval from the initial to the first maintenance dose (MD) was 14 days, ranging from 7 to 35 days. All centres used an MD of 100 μg. The most frequent time interval between subsequent MDs was 4 weeks (58%, n = 18). Five years' of VIT was declared by 71% (n = 22). Before the termination of treatment, more than half of the centres (58%, n = 18) performed sIgE and almost half (42%, n = 13) performed skin tests. To confirm VIT efficacy, few centres (26%, n = 8) conducted the sting challenge. About half of centres provided the patients with an adrenalin auto-injector both at the time of initial diagnostics and at the end of treatment. More than half (55%, n = 17) used antihistamines in all patients. Almost half (45%, n = 14) declared to stop treatment with β-blockers and almost one fourth (23%, n = 7) discontinued angiotensin-converting-enzyme inhibitors.

CONCLUSIONS

In the most important procedures, there is a very high compliance with the guidelines. In the areas where the guidelines are not precise, we observed a large spread of results.

A review on Respiratory allergy caused by insects

Hypersensitivity or allergy encompasses a wide range of immunological reactions that generally have adverse consequences involving one or many organ systems of the body. Allergens are usually glycoprotein or chemically complex low molecular weight substances. The common allergens include pollen, fungal spores, house dust mite and house dust, animal danders, drugs, foods, insect emanations, and detritus, etc. Information on the role of insects in respiratory allergy is increasing in the literature. There are about 30 million living species of insects. These insects can broadly be classified as stinging insects, biting insects and non-stinging and non-biting insects. All materials form insets namely wings, scales, saliva; dried feces and venom can cause allergic diseases, such as rhinitis, conjunctivitis, asthma and urticaria. There are wide varieties of insects such as moths, butterflies, bees, wasps, hornets, yellow jackets, flies, beetles, cockroaches, and mosquitoes. Exposure to emanations and detritus of these insects may lead to several allergies in some genetically predisposed individuals. Therefore, it is of interest to review allergies caused by various insect's stings and bites and their adverse effect on the human body.

The Epidemiology of Anaphylaxis

Anaphylaxis is a dramatic expression of systemic allergy. The lifetime prevalence of anaphylaxis is currently estimated at 0.05-2 % in the USA and ~3 % in Europe. Several population-specific studies have noted a rise in the incidence, particularly in the hospitalizations and ER visits due to anaphylaxis. The variable signs and symptoms that constitute the diagnostic criteria for anaphylaxis, the differences in diagnostic algorithms, and the limitations in the current coding systems have made summarizing epidemiologic data and comparing study results challenging. Nevertheless, across all studies, the most common triggers continue to be medications, food, and venom. Various risk factors for more severe reactions generally include older age, history of asthma, and having more comorbid diseases. Interesting seasonal, geographic, and latitude differences have been observed in anaphylaxis prevalence and incidence rates, suggesting a possible role of vitamin D and sun exposure in modifying anaphylaxis risk. While the incidence and prevalence of anaphylaxis appear to be increasing in certain populations, the overall fatality rate remains relatively low.

New modalities of allergen immunotherapy

Allergen immunotherapy is a rapidly evolving field. Although subcutaneous immunotherapy has been practiced for over a hundred years, improved understanding of the underlying immunological mechanisms has led to the development of new, efficacious and better tolerated allergen-derivatives, adjuvants and encapsulated allergens. Diverse routes of allergen immunotherapy - oral, sublingual, epicutanoeus and intralymphatic - are enabling immunotherapy for anaphylactic food allergies and pollen-food allergy syndrome, while improving the tolerability and effectiveness of aeroallergen immunotherapy. The addition of Anti-IgE therapy decreases adverse effects of subcutaneous and oral immunotherapy.

Life-Threatening Allergies: Using a Patient-Engaged Approach

BACKGROUND

Adolescents at risk for anaphylaxis are a growing concern. Novel training methods are needed to better prepare individuals to manage anaphylaxis in the community.

INTRODUCTION

Didactic training as the sole method of anaphylaxis education has been shown to be ineffective. We developed a smartphone-based interactive teaching tool with decision support and epinephrine auto-injector (EAI) training to provide education accessible beyond the clinic.

METHODS

This study consisted of two parts: (1) Use of food allergy scenarios to assess the decision support's ability to improve allergic reaction management knowledge. (2) An assessment of our EAI training module on participant's ability to correctly demonstrate the use of an EAI by comparing it to label instructions.

RESULTS

Twenty-two adolescents were recruited. The median (range) baseline number of correct answers on the scenarios before the intervention was 9 (3-11). All subjects improved with decision support, increasing to 11 (9-12) (p < .001). The median (range) demonstration score was 6 (5-6) for the video training module group and 4.5 (3-6) for the label group (p < 0.001).

DISCUSSION

Results suggest that the use of this novel m-health application can improve anaphylaxis symptom recognition and increase the likelihood of choosing the appropriate treatment. In addition, performing EAI steps in conjunction with the video training resulted in more accurate medication delivery with fewer missed steps compared to the use of written instructions alone.

CONCLUSION

The results suggest that mobile health decision support technology for anaphylaxis emergency preparedness may support traditional methods of training by providing improved access to anaphylaxis training in the community setting.

The culprit insect but not severity of allergic reactions to bee and wasp venom can be determined by molecular diagnosis

Background

Allergy to bee and wasp venom can lead to life-threatening systemic reactions. The identification of the culprit species is important for allergen-specific immunotherapy.

Objectives

To determine a panel of recombinant bee and wasp allergens which is suitable for the identification of bee or wasp as culprit allergen sources and to search for molecular surrogates of clinical severity of sting reactions.

Methods

Sera from eighty-seven patients with a detailed documentation of their severity of sting reaction (Mueller grade) and who had been subjected to titrated skin testing with bee and wasp venom were analyzed for bee and wasp-specific IgE levels by ImmunoCAP^TM. IgE-reactivity testing was performed using a comprehensive panel of recombinant bee and wasp venom allergens (rApi m 1, 2, 3, 4, 5 and 10; rVes v 1 and 5) by ISAC chip technology, ImmunoCAP and ELISA. IgG₄ antibodies to rApi m 1 and rVes v 5 were determined by ELISA and IgE/IgG₄ ratios were calculated. Results from skin testing, IgE serology and IgE/IgG₄ ratios were compared with severity of sting reactions.

Results

The panel of rApi m 1, rApi m 10, rVes v 1 and rVes v 5 allowed identification of the culprit venom in all but two of the 87 patients with good agreement to skin testing. Severities of sting reactions were not associated with results obtained by skin testing, venom-specific IgE levels or molecular diagnosis. Severe sting reactions were observed in patients showing < 1 ISU and < 2kU_A/L of IgE to Api m 1 and/or Ves v 5.

Conclusion

We identified a minimal panel of recombinant bee and wasp allergens for molecular diagnosis which may permit identification of bee and/or wasp as culprit insect in venom-sensitized subjects. The severity of sting reactions was not associated with parameters obtained by molecular diagnosis.

Analysis of Hymenoptera venom allergy in own material. Clinical evaluation of reactions following stings, in patients qualified for venom immunotherapy

Introduction

Hymenoptera venom allergy (HVA) in some patients occurs with general symptoms involving respiratory and cardiovascular system with anaphylactic shock with constitutes a significant threat to life.

Aim

Assessment of the prevalence of HVA in our own material.

Material and methods

There were 498 patients after a general reaction to wasp and/or bee venom. The survey included questions: the type of stinging insect, body parts stung by insects, profession, frequency of stings by wasps and bees depending on professional activity, places of stings, clinical symptoms using the scale according to Muller, and the treatment following the sting. Among 498 patients, there were 281 women and 217 men.

Results

Wasp stings were more frequent and affected 382 (77%) persons, while bee stings affected 116 (23%) persons. Limbs constituted the most common area of the body stung by both wasps and bees. The sting was more frequent in rural areas and during summer rest. A severe systemic reaction (class III and IV according to Muller) occurred more often in people stung by bees. The most common medications included intravenous glucocorticosteroids, calcium preparations and antihistamines. Intramuscular Adrenaline injection was used in 48% of patients, while only 15% received its prescription as an emergency medication. Bee stings were the most common cause of severe systemic symptoms.

Conclusions

The treatment after the sting in a significant percentage of episodes still deviates from the recommendations of the guidelines, especially in the field of adrenaline recommendations for patients in case of a resting by an insect

Venom immunotherapy in patients with allergic reactions to insect stings

INTRODUCTION

Allergy to Hymenoptera (Apis mellifera, Vespula species, Polistes species, Vespa crabro) venom can be safely and effectively treated by venom immunotherapy (VIT), which in the 40 years since its introduction has been able to prevent reactions to stings, and to treatment as well, though systemic reactions, occasionally severe, are possible. Areas covered: We reviewed the recent literature on VIT by searching in PubMed for the terms 'venom immunotherapy' and 'Hymenoptera venom immunotherapy' to highlight the current status of VIT and the likely development in the coming years. Expert commentary: VIT, provided the correct choice of the venom and adequate venom preparations and maintenance doses are used, is a treatment of great value in preventing systemic reactions to Hymenoptera stings. A 5-year duration ensures a prolonged tolerance to stings following VIT discontinuation, unless patients suffer from mastocytosis. In fact, due to reports of fatal reactions after stopping VIT, patients with mastocytosis, or with very severe reactions to stings, need an indefinite duration of treatment.

Update on Potential Therapies for IgE-Mediated Food Allergy

PURPOSE OF REVIEW

Food allergy is common, affecting up to 8% of children in the USA. Currently, therapy is limited to avoidance of the implicated allergen and availability of self-injectable epinephrine. However, several new approaches to food allergy are under investigation. This article reviews the published data on these new approaches.

RECENT FINDINGS

Oral immunotherapy, in which allergic subjects are exposed to increasing amounts of antigen, can be accomplished in the majority of allergic individuals. However, this approach is not a cure as most patients will react after cessation of regular intake. In addition, there is a high rate of side effects. Other approaches include epicutaneous immunotherapy, therapy with anti-IgE medications, and use of Chinese herbs. Several novel approaches on food allergy are under study. At the current time, these approaches show promise for preventing severe reactions to accidental exposures. However, there is little evidence that current approaches will represent a true cure for food allergy.

Acquired C1 Inhibitor Deficiency

Acquired angioedema due to C1-INH deficiency (C1-INH-AAE) can occur when there are acquired (not inherited) deficiencies of C1-INH. A quantitative or functional C1-INH deficiency with negative family history and low C1q is diagnostic of C1-INH-AAE. The most common conditions associated with C1-INH-AAE are autoimmunity and B-cell lymphoproliferative disorders. A diagnosis of C1-INH-AAE can precede a diagnosis of lymphoproliferative disease and confers an increased risk for developing non-Hodgkin lymphoma. Treatment focuses on symptom control with therapies that regulate bradykinin activity (C1-INH concentrate, icatibant, ecallantide, tranexamic acid, androgens) and treatment of any underlying conditions.

Diagnostics in Hymenoptera venom allergy: current concepts and developments with special focus on molecular allergy diagnostics

Background

The high rate of asymptomatic sensitization to Hymenoptera venom, difficulty in correctly identifying Hymenoptera and loss of sensitization over time make an accurate diagnosis of Hymenoptera venom allergy challenging. Although routine diagnostic tests encompassing skin tests and the detection of venom-specific IgE antibodies with whole venom preparations are reliable, they offer insufficient precision in the case of double sensitized patients or in those with a history of sting anaphylaxis, in whom sensitization cannot be proven or only to the presumably wrong venom.

Methods

Systematic literature research and review of current concepts of diagnostic testing in Hymenoptera venom allergy.

Results and discussion

Improvements in diagnostic accuracy over recent years have mainly been due to the increasing use of molecular allergy diagnostics. Detection of specific IgE antibodies to marker and cross-reactive venom allergens improves the discrimination between genuine sensitization and cross-reactivity, and this provides a better rationale for prescribing venom immunotherapy. The basophil activation test has also increased diagnostic accuracy by reducing the number of Hymenoptera venom sensitizations overlooked with routine tests. This paper reviews current concepts of diagnostic testing in Hymenoptera venom allergy and suggests fields for further development.

Allergen Immunotherapy

Allergies affect a large proportion of the population. Allergies can adversely affect productivity, sleep, and quality of life and can lead to life-threatening reactions. Allergies can spread to affect multiple organ systems. Allergen immunotherapy is the only therapy that can change the natural history of allergic disease.

Insect Allergy

Insect bites and stings are common. Risk factors are mostly associated with environmental exposure. Most insect bites and stings result in mild, local, allergic reactions. Large local reactions and systemic reactions like anaphylaxis are possible. Common insects that bite or sting include mosquitoes, ticks, flies, fleas, biting midges, bees, and wasps. The diagnosis is made clinically. Identification of the insect should occur when possible. Management is usually supportive. For anaphylaxis, patients should be given epinephrine and transported to the emergency department for further evaluation. Venom immunotherapy (VIT) has several different protocols. VIT is highly effective in reducing systemic reactions and anaphylaxis.

Anaphylaxis

Anaphylaxis is an acute, systemic reaction mediated by immunoglobulin E hypersensitivity. Release of bioactive factors causes vasodilation and bronchiole constriction that can lead to hypotensive shock and asphyxiation. Differential diagnosis includes acute asthma, localized angioedema, syncope, and anxiety/panic attacks. Diagnostic tests lack specificity. Clinical diagnosis is based on demonstration of specific airway or cardiovascular compromise within proximity of allergen exposure. Treatment includes epinephrine, antihistamines, fluid resuscitation, and airway management. Prevention focuses on awareness/avoidance of triggers, implementation of personalized action plans, as well as immune modulation by desensitization in a closely controlled setting where available.

Managing anaphylaxis in the office setting

BACKGROUND

Although the definition of anaphylaxis for clinical use may vary by professional health care organizations and individuals, the definition consistently includes the concepts of a serious, generalized or systemic, allergic or hypersensitivity reaction that can be life-threatening or even fatal.

METHODS

In this review, we presented the important topics in the treatment of anaphylaxis in the office setting. This review will discuss triggers and risk factors, clinical diagnosis, and management of anaphylaxis in the office setting.

RESULTS

Anaphylaxis in the office setting is a medical emergency. It, therefore, is important to prepare for it, to have a posted, written anaphylaxis emergency protocol, and to rehearse the plan regularly. In this review, we presented the important steps in managing anaphylaxis in the office. Treatment of anaphylaxis should start with epinephrine administered intramuscularly at the first sign of anaphylaxis. Oxygen and intravenous fluids may be needed for moderate-to-severe anaphylaxis or anaphylaxis that is quickly developing or if the patient is unresponsive to the first injection of epinephrine. Antihistamine therapy is considered adjunctive to epinephrine, which mainly relieves itching and urticaria. Corticosteroids, with an onset of action of 4-6 hours, have no immediate effect on anaphylaxis.

CONCLUSION

To prevent near-fatal and fatal reactions from anaphylaxis, the patient, the family, and the physician must remember to follow the necessary steps when treating anaphylaxis. In anaphylaxis, there is no absolute contraindication for epinephrine.

Epinephrine for First-aid Management of Anaphylaxis

Anaphylaxis is a severe, generalized allergic or hypersensitivity reaction that is rapid in onset and may cause death. Epinephrine (adrenaline) can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. This clinical report from the American Academy of Pediatrics is an update of the 2007 clinical report on this topic. It provides information to help clinicians identify patients at risk of anaphylaxis and new information about epinephrine and epinephrine autoinjectors (EAs). The report also highlights the importance of patient and family education about the recognition and management of anaphylaxis in the community. Key points emphasized include the following: (1) validated clinical criteria are available to facilitate prompt diagnosis of anaphylaxis; (2) prompt intramuscular epinephrine injection in the mid-outer thigh reduces hospitalizations, morbidity, and mortality; (3) prescribing EAs facilitates timely epinephrine injection in community settings for patients with a history of anaphylaxis and, if specific circumstances warrant, for some high-risk patients who have not previously experienced anaphylaxis; (4) prescribing epinephrine for infants and young children weighing <15 kg, especially those who weigh 7.5 kg and under, currently presents a dilemma, because the lowest dose available in EAs, 0.15 mg, is a high dose for many infants and some young children; (5) effective management of anaphylaxis in the community requires a comprehensive approach involving children, families, preschools, schools, camps, and sports organizations; and (6) prevention of anaphylaxis recurrences involves confirmation of the trigger, discussion of specific allergen avoidance, allergen immunotherapy (eg, with stinging insect venom, if relevant), and a written, personalized anaphylaxis emergency action plan; and (7) the management of anaphylaxis also involves education of children and supervising adults about anaphylaxis recognition and first-aid treatment.

Allergen immunotherapy for insect venom allergy: a systematic review and meta-analysis

BACKGROUND

The European Academy of Allergy and Clinical Immunology (EAACI) is in the process of developing the EAACI Guidelines on Allergen Immunotherapy (AIT) for the management of insect venom allergy. To inform this process, we sought to assess the effectiveness, cost-effectiveness and safety of AIT in the management of insect venom allergy.

METHODS

We undertook a systematic review, which involved searching 15 international biomedical databases for published and unpublished evidence. Studies were independently screened and critically appraised using established instruments. Data were descriptively summarized and, where possible, meta-analysed.

RESULTS

Our searches identified a total of 16 950 potentially eligible studies; of which, 17 satisfied our inclusion criteria. The available evidence was limited both in volume and in quality, but suggested that venom immunotherapy (VIT) could substantially reduce the risk of subsequent severe systemic sting reactions (OR = 0.08, 95% CI 0.03-0.26); meta-analysis showed that it also improved disease-specific quality of life (risk difference = 1.41, 95% CI 1.04-1.79). Adverse effects were experienced in both the build-up and maintenance phases, but most were mild with no fatalities being reported. The very limited evidence found on modelling cost-effectiveness suggested that VIT was likely to be cost-effective in those at high risk of repeated systemic sting reactions and/or impaired quality of life.

CONCLUSIONS

The limited available evidence suggested that VIT is effective in reducing severe subsequent systemic sting reactions and in improving disease-specific quality of life. VIT proved to be safe and no fatalities were recorded in the studies included in this review. The cost-effectiveness of VIT needs to be established.

Hymenoptera venom allergy in outdoor workers: Occupational exposure, clinical features and effects of allergen immunotherapy

OBJECTIVES

To describe (i) the clinical characteristics of workers, exposed to hymenoptera stings, with an ascertained diagnosis of Hymenoptera Venom Allergy (HVA), (ii) the specific role of occupational exposure, (iii) the effect of Venom Immunotherapy (VIT) in reducing the severity of allergic episodes in workers exposed to repeated stings of hymenoptera, and (iv) the management of the occupational consequences caused by allergic reactions due to hymenoptera stings.

METHODS

Between 2000 and 2013 an observational study, including patients referred to the regional reference hospital of Liguria, Italy, with an ascertained diagnosis of HVA and treated with VIT, was performed. A structured questionnaire was administered to all patients to investigate the occupational features of allergic reactions. These were graded according to standard systems in patients at the first episode, and after re-stings, during VIT.

RESULTS

One-hundred and 8four out of the 202 patients referred had a complete data set. In 32 (17.4%) patients, the allergic reaction occurred during work activities performed outdoor. Of these, 31.2% previously stung by hymenoptera at work, and receiving VIT, were re-stung during occupational activity. The grades of reaction developed under VIT treatment resulted clinically less severe than of those occurred at the first sting (p-value = 0.031).

CONCLUSION

Our findings confirmed the clinical relevance of HVA, and described its occupational features in outdoor workers with sensitization, stressing the importance of an early identification and proper management of the professional categories recognized at high risk of hymenoptera stings. The Occupational Physician should be supported by other specialists to recommend appropriate diagnostic procedures and the prescription of VIT, which resulted an effective treatment for the prevention of episodes of severe reactions in workers with a proven HVA.