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Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024:S2213-2198(24)00845-6. [PMID: 39173970 DOI: 10.1016/j.jaip.2024.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/20/2024] [Accepted: 08/05/2024] [Indexed: 08/24/2024]
Abstract
Understanding the risk factors leading to severe systemic sting reactions (SSRs) is crucial for initiating venom immunotherapy (VIT) and for educating affected individuals and their families. Some of these risk factors are well established, some are no longer considered risk factors, and some remain controversial. Well-established risk factors for severe SSRs include clonal mast cell disease, high baseline serum tryptase, and advanced age. The absence of skin symptoms and the rapid onset of symptoms are indicators of severe SSRs. Recent publications indicate that antihypertensive treatment and stings in the head and neck area are not risk factors for severe SSRs. VIT is the only available treatment that can potentially prevent further anaphylactic reactions. Although rare and generally manageable, individuals undergoing VIT may experience systemic adverse events (sAEs). More sAEs are expected in patients undergoing bee VIT compared with vespid VIT. The role of elevated baseline serum tryptase as a risk factor for sAEs remains debated, but if it is a factor, the risk is increased by only about 1.5-fold. Rapid updosing protocols, depending on the specific regimen, can also be associated with more sAEs. Severe initial SSRs, antihypertensive medication, high skin test reactivity, and high specific IgE levels are not risk factors for sAEs.
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Affiliation(s)
- Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria; Allergy Outpatient Clinic Reumannplatz, Vienna, Austria.
| | - Eva Schadelbauer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Giorgia Marta
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Mitja Kosnik
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Pawłowicz R, Bożek A, Dor-Wojnarowska A, Rosiek-Biegus M, Kopeć A, Gillert-Smutnicka M, Sobieszczańska M, Nittner-Marszalska M. Elderly Patients and Insect Venom Allergy: Are the Clinical Pictures and Immunological Parameters of Venom Allergy Age-Dependent? Vaccines (Basel) 2024; 12:394. [PMID: 38675776 PMCID: PMC11053896 DOI: 10.3390/vaccines12040394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 04/28/2024] Open
Abstract
Insect venom is one of the most common triggers of anaphylaxis in the elderly population. Venom immunotherapy (VIT) remains the only treatment for Hymenoptera venom allergy (HVA). However, little is known about the differences in indication for VIT in the group of patients aged 60 years and older. The objective of this study was to assess the clinical and diagnostic differences of HVA in elderly patients. The study compared data from patients aged ≥ 60 (N = 132) to data from patients aged from 11 to 60 years (N = 750) in terms of HVA severity, comorbidities, and immunological parameters, namely, intradermal testing (IDT), specific IgE (sIgE) levels against extracts and major allergenic molecules, and serum tryptase level (sBT). The severity of systemic HVA (I-IV Müller scale) did not differ between adults and seniors. However, the severity of cardiovascular reactions (IV) increased with age, while the frequency of respiratory reactions (III) decreased. No differences were found in the immunological parameters of sensitization IDT, venom-specific IgE concentrations, or sIgE against Api m 1, 2, 4, 5, and 10 between patients below and above 60 or 65 years of age. Differences were noted for sIgE against Ves v1 and Ves v5; they were higher and lower, respectively, in seniors. In the seniors group, sBT levels were higher. Elevated tryptase levels, along with the aging process, can represent a risk factor within this age category. Nevertheless, advanced age does not influence the immunological parameters of immediate HVA reactions, nor does it impact the diagnosis of HVA.
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Affiliation(s)
- Robert Pawłowicz
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland; (A.D.-W.); (M.R.-B.); (A.K.); (M.N.-M.)
| | - Andrzej Bożek
- Clinical Department of Internal Diseases, Dermatology and Allergology, Medical University of Silesia, Sklodowskiej 10, 41-800 Zabrze, Poland;
| | - Anna Dor-Wojnarowska
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland; (A.D.-W.); (M.R.-B.); (A.K.); (M.N.-M.)
| | - Marta Rosiek-Biegus
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland; (A.D.-W.); (M.R.-B.); (A.K.); (M.N.-M.)
| | - Agnieszka Kopeć
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland; (A.D.-W.); (M.R.-B.); (A.K.); (M.N.-M.)
| | | | - Małgorzata Sobieszczańska
- Clinical Department of Geriatrics, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland;
| | - Marita Nittner-Marszalska
- Clinical Department of Internal Medicine, Pneumology and Allergology, Wroclaw Medical University, Chałbińskiego 1a, 50-368 Wrocław, Poland; (A.D.-W.); (M.R.-B.); (A.K.); (M.N.-M.)
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Lee JH, Kim MJ, Park YS, Kim E, Chung HS, Chung SP. Severe Systemic Reactions Following Bee Sting Injuries in Korea. Yonsei Med J 2023; 64:404-412. [PMID: 37226567 DOI: 10.3349/ymj.2022.0532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 05/26/2023] Open
Abstract
PURPOSE Most bee sting injuries are benign, although sometimes they can result in life threatening outcomes, such as anaphylaxis and death. The purpose of this study was to investigate the epidemiologic status of bee sting injuries in Korea and to identify risk factors associated with severe systemic reactions (SSRs). MATERIALS AND METHODS Cases were extracted from a multicenter retrospective registry for patients who had visited emergency departments (EDs) for bee sting injuries. SSRs were defined as hypotension or altered mental status upon ED arrival, hospitalization, or death. Patient demographics and injury characteristics were compared between SSR and non-SSR groups. Logistic regression was performed to identify risk factors for bee sting-associated SSRs, and the characteristics of fatality cases were summarized. RESULTS Among the 9673 patients with bee sting injuries, 537 had an SSR and 38 died. The most frequent injury sites included the hands and head/face. Logistic regression analysis revealed that the occurrence of SSRs was associated with male sex [odds ratio (95% confidence interval); 1.634 (1.133-2.357)] and age [1.030 (1.020-1.041)]. Additionally, the risk of SSRs from trunk and head/face stings was high [2.858 (1.405-5.815) and 2.123 (1.333-3.382), respectively]. Bee venom acupuncture [3.685 (1.408-9.641)] and stings in the winter [4.573 (1.420-14.723)] were factors that increased the risk of SSRs. CONCLUSION Our findings emphasize the need for implementing safety policies and education on bee sting-related incidents to protect high-risk groups.
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Affiliation(s)
- Ji Hwan Lee
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - EungNam Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Hollstein MM, Matzke SS, Lorbeer L, Forkel S, Fuchs T, Lex C, Buhl T. Intracutaneous Skin Tests and Serum IgE Levels Cannot Predict the Grade of Anaphylaxis in Patients with Insect Venom Allergies. J Asthma Allergy 2022; 15:907-918. [PMID: 35836970 PMCID: PMC9274911 DOI: 10.2147/jaa.s367272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background Allergies against Hymenoptera venoms are a major cause of severe anaphylaxis. Risk assessment for subjects with suspected allergy is difficult because there are currently no biomarkers that predict the likelihood of high-grade anaphylaxis other than several associated comorbidities. Objective We investigated the relationship between the severity of anaphylaxis and the results of intracutaneous skin tests (ICTs) together with serum levels of tryptase, total IgE, and venom-specific IgE, IgG, and IgG4. Methods We performed a retrospective evaluation of 194 patients who presented to a single medical center with allergies to bee venoms (Apis mellifera, Bombus spp.; n=24, 12.4%), vespid venoms (Vespula spp., Vespa spp., Polistes spp.; n=169, 87.1%), or both (n=1, 0.5%). Results Index bee stings occurred earlier in the year than vespid stings, although the latter were reported more frequently overall. On average, subjects who previously experienced grade IV anaphylaxis required higher dosages of venom to yield positive ICTs than those who exhibited lower grade responses. Patients diagnosed with grade IV anaphylaxis exhibited significantly lower levels of venom-specific IgE and IgG and trended toward elevated levels of tryptase. No significant differences in average levels of venom-specific IgG4 and total IgE were observed. Conclusion Our findings reveal that intracutaneous skin testing and levels of venom-specific IgE do not predict the degree of anaphylaxis that develops in patients with venom allergy. Furthermore, the month of the index sting is not a reliable means to differentiate bee from vespid stings in patients presenting with an uncertain history.
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Affiliation(s)
- Moritz M Hollstein
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Silke S Matzke
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Lisa Lorbeer
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Susann Forkel
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Christiane Lex
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology with Pediatric Pneumology, University Medical Centre Göttingen, Göttingen, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
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Risikofaktoren bei Bienen- und Wespengiftallergie: aktuelle Bewertung. ALLERGO JOURNAL 2022. [DOI: 10.1007/s15007-021-4938-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Chatain C, Sedillot N, Thomas M, Pernollet M, Bocquet A, Boccon-Gibod I, Bouillet L, Leccia MT. Fatal hymenoptera venom anaphylaxis by undetected clonal mast cell disorder: A better identification of high risk patients is needed. Rev Med Interne 2021; 42:869-874. [PMID: 34776279 DOI: 10.1016/j.revmed.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 07/21/2021] [Accepted: 08/01/2021] [Indexed: 10/19/2022]
Abstract
Hymenoptera venom anaphylaxis is the most frequent cause of anaphylaxis and responsible for about 20% of all fatal anaphylaxis cases in adults. We report two cases of fatal hymenoptera venom anaphylaxis with undiagnosed underlying mastocytosis and review the risk factors for severe or fatal hymenoptera venom anaphylaxis, as well as the specificities of its association with mastocytosis. As hymenoptera venom allergic patients with underlying clonal mast cell disorder generally lack typical skin lesions of mastocytosis, its diagnosis can easily be missed, underscoring the importance and need for diagnostic strategies in order to correctly identify these patients. Predominant cardiovascular symptoms in the absence of urticaria or angioedema following an insect sting are suggestive of underlying clonal mast cell disorder, and should be distinguished from panic attack or vasovagal syncope. Similarly, an unexplained syncope or an "idiopathic" anaphylaxis might reveal mastocytosis or hereditary alpha-tryptasemia. Acute and basal serum tryptase measurements should always be integrated in the diagnostic work-up of an insect sting reaction or unexplained syncope or shock of any origin.
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Affiliation(s)
- C Chatain
- Department of Dermatology, Allergology and Photobiology, University Hospital Center Grenoble Alpes, Grenoble, France.
| | - N Sedillot
- Intensive Care Unit, University Hospital Center Grenoble Alpes, Grenoble, France
| | - M Thomas
- Intensive Care Unit, University Hospital Center Grenoble Alpes, Grenoble, France
| | - M Pernollet
- Laboratory of Immunology, Institute of Biology and Pathology, University Hospital Center Grenoble Alpes, Grenoble, France
| | - A Bocquet
- Department of Dermatology, Allergology and Photobiology, University Hospital Center Grenoble Alpes, Grenoble, France; Department of Internal Medicine, University Hospital Center Grenoble Alpes, Grenoble, France
| | - I Boccon-Gibod
- Department of Internal Medicine, University Hospital Center Grenoble Alpes, Grenoble, France
| | - L Bouillet
- Department of Internal Medicine, University Hospital Center Grenoble Alpes, Grenoble, France
| | - M T Leccia
- Department of Dermatology, Allergology and Photobiology, University Hospital Center Grenoble Alpes, Grenoble, France
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Sturm GJ, Herzog SA, Aberer W, Alfaya Arias T, Antolín‐Amérigo D, Bonadonna P, Boni E, Bożek A, Chełmińska M, Ernst B, Frelih N, Gawlik R, Gelincik A, Hawranek T, Hoetzenecker W, Jiménez Blanco A, Kita K, Kendirlinan R, Košnik M, Laipold K, Lang R, Marchi F, Mauro M, Nittner‐Marszalska M, Poziomkowska‐Gęsicka I, Pravettoni V, Preziosi D, Quercia O, Reider N, Rosiek‐Biegus M, Ruiz‐Leon B, Schrautzer C, Serrano P, Sin A, Sin BA, Stoevesandt J, Trautmann A, Vachová M, Arzt‐Gradwohl L. β-blockers and ACE inhibitors are not a risk factor for severe systemic sting reactions and adverse events during venom immunotherapy. Allergy 2021; 76:2166-2176. [PMID: 33605465 PMCID: PMC8359427 DOI: 10.1111/all.14785] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/06/2021] [Accepted: 01/20/2021] [Indexed: 11/28/2022]
Abstract
Background There is controversy whether taking β‐blockers or ACE inhibitors (ACEI) is a risk factor for more severe systemic insect sting reactions (SSR) and whether it increases the number or severity of adverse events (AE) during venom immunotherapy (VIT). Methods In this open, prospective, observational, multicenter trial, we recruited patients with a history of a SSR and indication for VIT. The primary objective of this study was to evaluate whether patients taking β‐blockers or ACEI show more systemic AE during VIT compared to patients without such treatment. Results In total, 1,425 patients were enrolled and VIT was performed in 1,342 patients. Of all patients included, 388 (27.2%) took antihypertensive (AHT) drugs (10.4% took β‐blockers, 11.9% ACEI, 5.0% β‐blockers and ACEI). Only 5.6% of patients under AHT treatment experienced systemic AE during VIT as compared with 7.4% of patients without these drugs (OR: 0.74, 95% CI: 0.43–1.22, p = 0.25). The severity of the initial sting reaction was not affected by the intake of β‐blockers or ACEI (OR: 1.14, 95% CI: 0.89–1.46, p = 0.29). In total, 210 (17.7%) patients were re‐stung during VIT and 191 (91.0%) tolerated the sting without systemic symptoms. Of the 19 patients with VIT treatment failure, 4 took β‐blockers, none an ACEI. Conclusions This trial provides robust evidence that taking β‐blockers or ACEI does neither increase the frequency of systemic AE during VIT nor aggravate SSR. Moreover, results suggest that these drugs do not impair effectiveness of VIT. (Funded by Medical University of Graz, Austria; Clinicaltrials.gov number, NCT04269629).
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Affiliation(s)
- Gunter Johannes Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Allergy Outpatient Clinic Reumannplatz Vienna Austria
| | - Sereina Annik Herzog
- Center for Health Economics Research and Modelling Infectious Diseases (CHERMID) Vaccine & Infectious Disease Institute (VAXINFECTIO) University of Antwerp Antwerp Belgium
- Institute for Medical Informatics, Statistics, and Documentation Medical University of Graz Graz Austria
| | - Werner Aberer
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
| | - Teresa Alfaya Arias
- Allergy UnitHospital General Universitario de Ciudad Real & Hospital Universitario Fundación Alcorcón Madrid Spain
| | - Darío Antolín‐Amérigo
- Servicio de Enfermedades del Sistema Inmune‐Alergia Hospital Universitario Príncipe de Asturias Departamento de Medicina y EspecialidadesMédicas Universidad de Alcalá Madrid Spain
- Servicio de Alergia Hospital Universitario Ramón y Cajal (IRYCIS Madrid Spain
| | | | - Elisa Boni
- Laboratorio Unico Metropolitano Maggiore Hospital Bologna Italy
| | - Andrzej Bożek
- Clinical Department of Internal Diseases, Dermatology, and Allergology Medical University of Silesia Zabrze Poland
| | - Marta Chełmińska
- Allergology Department Medical University of Gdańsk Gdańsk Poland
| | - Barbara Ernst
- Department of Dermatology General Hospital Ordensklinikum Linz GmbH Elisabethinen Linz Austria
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - Radoslaw Gawlik
- Department of Internal Medicine, Allergy, and Clinical Immunology Silesian University of Medicine Katowice Poland
| | - Asli Gelincik
- Department of Internal Medicine Division of Immunology and Allergic Diseases Istanbul Faculty of Medicine Istanbul University Istanbul Turkey
| | - Thomas Hawranek
- Department of Dermatology and Allergology Paracelsus Medical University Salzburg Salzburg Austria
| | - Wolfram Hoetzenecker
- Department of Dermatology Kepler University Hospital and Medical FacultyJohannes Kepler University Linz Austria
| | - Aránzazu Jiménez Blanco
- Allergy Unit Hospital Central de la Cruz Roja Faculty of Medicine Alfonso X El Sabio UniversityARADyAL Madrid Spain
| | - Karolina Kita
- Allergology Department Medical University of Gdańsk Gdańsk Poland
| | - Reşat Kendirlinan
- Department of Pulmonary Diseases Division of Immunology and Allergy Faculty of Medicine Ankara University Ankara Turkey
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases, Golnik and Medical Faculty Ljubljana Ljubljana Slovenia
| | - Karin Laipold
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
| | - Roland Lang
- Department of Dermatology and Allergology Paracelsus Medical University Salzburg Salzburg Austria
| | - Francesco Marchi
- SD Allergologia ClinicaAzienda Ospedaliero‐Universitaria Pisana Pisa Italy
| | | | - Marita Nittner‐Marszalska
- Department of Internal Diseases, Pulmonology and Allergology Medical University of Wroclaw Wroclaw Poland
| | | | - Valerio Pravettoni
- UOC General Medicine Immunology and Allergology IRCCS Foundation CaGranda Ospedale Maggiore Policlinico Milan Italy
| | | | - Oliviero Quercia
- High Specialization Unit of Allergology Hospital of Faenza AUSL (Local Health Unit) of Romagna Romagna Italy
| | - Norbert Reider
- Department of Dermatology, Venereology, and Allergology Medical University of Innsbruck Innsbruck Austria
| | - Marta Rosiek‐Biegus
- Department of Internal Diseases, Pulmonology and Allergology Medical University of Wroclaw Wroclaw Poland
| | - Berta Ruiz‐Leon
- Maimonides Biomedical Research Institute of Cordoba (IMIBICAvenida Menéndez Pidal S/N Córdoba Spain
- Unidad de GestiónClínica de Inmunoalergia & ARADyAL Research Network Reina Sofía University Hospital Córdoba Spain
| | - Christoph Schrautzer
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
| | - Pilar Serrano
- Maimonides Biomedical Research Institute of Cordoba (IMIBICAvenida Menéndez Pidal S/N Córdoba Spain
- Unidad de GestiónClínica de Inmunoalergia & ARADyAL Research Network Reina Sofía University Hospital Córdoba Spain
| | - Aytül Sin
- Department of Internal Medicine Division of Allergy and Immunology Medical Faculty Ege University Izmir Turkey
| | - Betül Ayşe Sin
- Department of Pulmonary Diseases Division of Immunology and Allergy Faculty of Medicine Ankara University Ankara Turkey
| | - Johanna Stoevesandt
- Department of Dermatology and Allergy University Hospital Würzburg Würzburg Germany
| | - Axel Trautmann
- Department of Dermatology and Allergy University Hospital Würzburg Würzburg Germany
| | - Martina Vachová
- Department of Immunology and Allergology Faculty of Medicine in Pilsen Charles University Pilsen Czech Republic
| | - Lisa Arzt‐Gradwohl
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
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Kopač P, Custovic A, Zidarn M, Šilar M, Šelb J, Bajrović N, Eržen R, Košnik M, Korošec P. Biomarkers of the Severity of Honeybee Sting Reactions and the Severity and Threshold of Systemic Adverse Events During Immunotherapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3157-3163.e5. [PMID: 33962066 DOI: 10.1016/j.jaip.2021.04.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND A biomarker that could identify individuals at high risk for severe honeybee sting allergic reaction and/or systemic adverse events (SAEs) during venom immunotherapy (VIT) would improve the management of patients with honeybee (HB) venom allergy. OBJECTIVE To identify biomarkers for risk of severe sting reactions or SAEs during VIT. METHODS We recruited 332 patients undergoing HB VIT. We ascertained predictors of the severity of the field-sting reaction and the severity and threshold of SAEs during VIT. We assessed the use of cardiovascular medications; baseline serum tryptase (BST) levels; specific IgEs to HB venom, rApi m 1, and rApi m 10; and basophil activation test (BAT) response. RESULTS Significant and independent predictors of a severe HB field-sting reaction were age (P = .008), an absence of skin symptoms (P = .001), BST (P = .014), and BAT response at an HB venom concentration of 0.1 μg/mL (P = .001). Predictors of severe SAEs during HB VIT were age (P = .025), BST (P = .006), and BAT response (P = .001). BAT response was also an individual and significant predictor of any SAEs and SAEs at a low cumulative allergen dose (median, 55 μg) during VIT build-up (P < .001). The use of β-blockers and angiotensin-converting-enzyme inhibitors and specific IgE levels were not associated with the severity of HB field-sting reactions or VIT SAEs. CONCLUSIONS BST and basophil activation are independent risk factors for severe HB sting anaphylaxis and SAEs during HB VIT. BAT response was the best biomarker for any SAEs and a lower threshold of SAEs during HB VIT. These risk factors can help guide recommendations for VIT and overcome systemic reactions to HB VIT.
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Affiliation(s)
- Peter Kopač
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mihaela Zidarn
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mira Šilar
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Julij Šelb
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nissera Bajrović
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Renato Eržen
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia; Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Korošec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia
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Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JN, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy 2020; 75:535-545. [PMID: 31194889 DOI: 10.1111/all.13945] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/16/2019] [Accepted: 06/07/2019] [Indexed: 01/06/2023]
Abstract
Hymenoptera venom allergy ranks among the top three causes of anaphylaxis worldwide, and approximately one-quarter of sting-induced reactions are classified as severe. Fatal sting reactions are exceedingly rare, but certain factors may entail a considerably higher risk. Delayed administration of epinephrine and upright posture are situational risk factors which may determine an unfavorable outcome of the acute anaphylactic episode and should be addressed during individual patient education. Systemic mastocytosis and senior age are major, unmodifiable long-term risk factors and thus reinforce the indication for venom immunotherapy. Vespid venom allergy and male sex likewise augment the risk of severe or even fatal reactions. Further studies are required to assess the impact of specific cardiovascular comorbidities. Available data regarding potential effects of beta-blockers and/or ACE inhibitors in coexisting venom allergy are inconclusive and do not justify recommendations to discontinue guideline-directed antihypertensive treatment. The absence of urticaria/angioedema during sting-induced anaphylaxis is indicative of a severe reaction, serum tryptase elevation, and mast cell clonality. Determination of basal serum tryptase levels is an established diagnostic tool for risk assessment in Hymenoptera venom-allergic patients. Measurement of platelet-activating factor acetylhydrolase activity represents a complementary approach but is not available for routine diagnostic use.
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Affiliation(s)
- Johanna Stoevesandt
- Department of Dermatology, Venereology and Allergy & Allergy Center Mainfranken University Hospital Würzburg Würzburg Germany
| | - Gunter J. Sturm
- Department of Dermatology and Venereology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplatz Vienna Austria
| | - Patrizia Bonadonna
- Allergy Unit and Multidisciplinary Mastocytosis Outpatient Clinic Azienda Ospedaliera Universitaria Integrata of Verona Verona Italy
| | - Joanna N.G. Oude Elberink
- Department of Allergology & GRIAC Research Institute University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Axel Trautmann
- Department of Dermatology, Venereology and Allergy & Allergy Center Mainfranken University Hospital Würzburg Würzburg Germany
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Antolín-Amérigo D, Ruiz-León B, Vega-Castro A, de la Hoz Caballer B. Natural history of systemic reactions and risk factors in children and adults with Hymenoptera venom allergy. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-0745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sahiner UM, Durham SR. Hymenoptera Venom Allergy: How Does Venom Immunotherapy Prevent Anaphylaxis From Bee and Wasp Stings? Front Immunol 2019; 10:1959. [PMID: 31497015 PMCID: PMC6712168 DOI: 10.3389/fimmu.2019.01959] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Hymenoptera stings may cause both local and systemic allergic reactions and even life threatening anaphylaxis. Along with pharmaceutical drugs and foods, hymenoptera venom is one of the most common causes of anaphylaxis in humans. To date, no parameter has been identified that may predict which sensitized people will have a future systemic sting reaction (SSR), however some risk factors, such as mastocytosis and age >40 years are known. Venom immunotherapy (VIT) is the most effective method of treatment for people who had SSR, which is shown to be effective even after discontinuation of the therapy. Development of peripheral tolerance is the main mechanism during immunotherapy. It is mediated by the production of blocking IgG/IgG4 antibodies that may inhibit IgE dependent reactions through both high affinity (FcεRI) and low affinity (FcεRII) IgE receptors on mast cells, basophils and B cells. The generation of antigen specific regulatory T cells produces IL-10 and suppresses Th2 immunity and the immune responses shift toward a Th1-type response. B regulatory cells are also involved in the production of IL-10 and the development of long term immune tolerance. During VIT the number of effector cells in target organs also decreases, such as mast cells, basophils, innate type 2 lymphocytes and eosinophils. Several meta-analyses and randomized controlled studies have proved that VIT is effective for preventing SSR to a sting and improves the quality of life. In this review, the risk of SSR in venom allergy and how VIT changed this risk are discussed.
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Affiliation(s)
- Umit Murat Sahiner
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,Pediatric Allergy Department, Hacettepe University School of Medicine, Ankara, Turkey
| | - Stephen R Durham
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, London, United Kingdom.,MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
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Analysis of Hymenoptera venom allergy in own material. Clinical evaluation of reactions following stings, in patients qualified for venom immunotherapy. Postepy Dermatol Alergol 2018; 36:302-307. [PMID: 31333347 PMCID: PMC6640013 DOI: 10.5114/ada.2018.75607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 03/30/2018] [Indexed: 11/17/2022] Open
Abstract
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
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Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, Antolín-Amérigo D, Cichocka-Jarosz E, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Ollert M, Oude Elberink JNG, Pfaar O, Pitsios C, Pravettoni V, Ruëff F, Sin BA, Agache I, Angier E, Arasi S, Calderón MA, Fernandez-Rivas M, Halken S, Jutel M, Lau S, Pajno GB, van Ree R, Ryan D, Spranger O, van Wijk RG, Dhami S, Zaman H, Sheikh A, Muraro A. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy 2018; 73:744-764. [PMID: 28748641 DOI: 10.1111/all.13262] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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