Medical Algorithms: Diagnosis and treatment of Hymenoptera venom allergy

Basophil Activation Test in Double-Sensitized Patients With Hymenoptera Venom Allergy: Additional Benefit of Component-Resolved Diagnostics

BACKGROUND

In Hymenoptera venom allergy serologically double-sensitized patients, it is often difficult to identify the culprit insect for venom immunotherapy (VIT).

OBJECTIVES

To evaluate if basophil activation tests (BATs) performed not only with venom extracts but additionally with single component-resolved diagnostics could differentiate between sensitized and allergic individuals and how the test results influenced the physicians' decision regarding VIT.

METHODS

BATs were performed with bee and wasp venom extracts and with single components (Api m 1, Api m 10, Ves v 1, and Ves v 5) in 31 serologically double-sensitized patients.

RESULTS

In 28 finally included individuals, 9 BATs were positive and 4 negative for both venoms. Fourteen of 28 BATs showed positive results for wasp venom alone. Two of 10 BATs positive for bee venom were only positive to Api m 1 and 1 of 28 BATs only to Api m 10, but not for whole bee venom extract. Five of 23 BATs positive for wasp venom were only positive for Ves v 5 but negative for wasp venom extract and Ves v 1. Finally, VIT with both insect venoms was recommended in 4 of 28 individuals, with wasp venom alone in 21 of 28 patients and with bee venom alone in 1 of 28. In 2 cases no VIT was recommended.

CONCLUSIONS

BATs with Ves v 5, followed by Api m 1 and Api m 10, were helpful for the decision for VIT with the clinically relevant insect in 8 of 28 (28.6%) patients. A BAT with components should therefore be additionally carried out in cases with equivocal results.

Skin prick tests are not useful for the qualification for venom immunotherapy in children

Background

The basis for qualification for venom immunotherapy (VIT) is the fulfilment of both the clinical and immunological criteria. Diagnostic tests that confirm the immunological criterion of an IgE-mediated sensitization include skin prick tests (SPT), intradermal tests (IDT), and serum specific IgE (sIgE) for the culprit venom.

Objective

This study aimed to assess the usefulness of SPT as the immunological marker in the diagnosis of insect venom sensitization in children with history of systemic reaction (SR) to insect sting evaluated by means of I-IV-grades Mueller's scale. There are no such studies in children.

Methods

This cross-sectional study sample consisted of 416 children aged 3-18 years (mean age 10.6 ± 3.8), 76% males, all with the history of a systemic reaction (SR) after a Hymenoptera sting (48% of grade III/IV according to Mueller scale), diagnosed between 1999 and 2019 in the tertiary referral centre. The standard diagnostic tests were used. Specificity, sensitivity, and positive and negative predictive values were computed to assess the diagnostic properties of the clinical tests to distinguish between mild and severe SR. To assess the relative value of an individual test in predicting the qualification to VIT we incorporated the Shapley value (SV).

Results

Positive SPT results were found in up to no more than 3% of children; among them less than 1% had only positive SPT and were negative for sIgE and IDT. Approximately 85% of the children had detectable venom sIgE, followed by positive IDT (75%). Almost 70% of children had positive both sIgE and IDT results. In children with grade III/IV reaction, about 80% of children had positive results of both of these tests. sIgE and IDT had sensitivity >0.80, whereas SPT had high specificity (>0.97) in differentiating between mild and severe SR. Relative value of diagnostic tests in predicting qualification to VIT varied between venoms. Bee venom IDT had higher SV (0.052) than sIgE (0.041). In contrast, wasp venom sIgE had higher SV (0.075) than IDT (0.035).

Conclusion

SPTs are not an useful immunological marker of venom sensitization in children, and eliminating SPT does not result in a loss of diagnostic accuracy. Limiting diagnostics to venom sIgE and IDT would shorten the procedure and reduce costs. Future studies are needed to determine if venom sIgE as the first line diagnostic test, with IDT added only if the venom sIgE is undetectable, is an optimal diagnostic process.

Adverse reactions in venom immunotherapy protocols: conventional versus ultra-rush

BACKGROUND

Venom immunotherapy (VIT) is an effective treatment in the patients at high risk of anaphylaxis or life-threatening systemic reactions due to Hymenoptera venom allergy. But, systemic and large local reactions can be observed, especially during the build-up phase of VIT. We evaluated the safety of conventional and ultra-rush build-up protocols.

MATERIALS AND METHODS

Two protocols in 71 patients (39 conventional and 32 ultra-rush protocols) with honeybee and wasp venom allergy were evaluated retrospectively. Patients were diagnosed and selected for VIT according to the criteria established by the European Academy of Allergy and Clinical Immunology. The severity of systemic reactions was evaluated according to the criteria of Mueller.

RESULTS

Build-up phases were tolerated in 66.2% (n = 47) without any reaction. Allergic adverse reactions were observed in 33.8% (n = 24): large local reactions 22.5% (n = 16) and systemic reactions 11.3% (n = 8). There was no significant difference in the number of adverse reactions comparing patients receiving conventional and ultra-rush protocol. In addition, no association was found between allergic adverse reactions and the following factors: sex, previous systemic sting reactions, honeybee and wasp venom extract.

CONCLUSION

We found that both protocols were tolerated in patients with honeybee and wasp venom allergy. Ultra-rush protocol will be preferred for patients and clinicians because of its advantages in terms of time and costs.KEY MESSAGESVIT is the only curative treatment method that reduces the risk of severe reactions after a bee sting and improves the quality of life in patients with Hymenoptera venom allergy.Ultra-rush VIT protocol has advantages such as few injection and time savings.Both ultra-rush and conventional VIT are safe treatments to prevent potentially life-threatening reactions in patients with honeybee and wasp venom allergy.

Diagnosis of Hymenoptera Venom Allergy: State of the Art, Challenges, and Perspectives

Hymenoptera venom allergy is the most common cause of anaphylaxis in adults and the second-most frequent in children. The proper diagnosis of this life-threatening allergy remains a challenge. This review focuses on the current knowledge regarding diagnostics of Hymenoptera venom allergy. The paper includes a brief description of the representatives of Hymenoptera order and the composition of their venoms. Then, diagnostic tests for allergy to Hymenoptera venom are described. Common diagnostic problems, especially double positivity in tests for IgE antibodies specific to honeybee and wasp venom, are also discussed. Special attention is paid to the search for new diagnostic capabilities using modern methodologies. Multidimensional molecular analysis offers an opportunity to characterize changes in body fluids associated with Hymenoptera venom allergy and yields a unique insight into the cell status. Despite recent developments in the diagnostics of Hymenoptera venom allergy, new testing methodologies are still needed to answer questions and doubts we have.

[Allergy Diagnostics 2021]

Allergic diseases are among the most common diseases worldwide. For appropriate management knowledge of the allergy trigger is crucial. The clinical picture of allergic diseases is diverse and correct diagnosis is often a challenge. The allergist needs to distinguish intolerances from allergies and infectious diseases from non-infectious triggers. Test results have to be interpreted accordingly to differentiate sensitizations from allergies. In this review current state of the art diagnostic measures to diagnose type I and type IV allergies are described and discussed.Immediate type allergies such as allergic rhinoconjunctivitis, asthma and anaphylaxis are mediated by allergen-specific IgE antibodies detectable both in serum and tissue. Typical triggers are pollen, mites, animal epithelia, food, insect toxins and pharmaceuticals. In everyday practice, diagnostics are based on three complementary pillars: the allergy-specific anamnesis as a prerequisite of correct interpretation of subsequent diagnostic tests like skin testing and serological immunoglobulin detection. These can be supplemented as required and available by provocation tests to prove clinical reactivity and cellular assays to demonstrate the cellular immune response.Type IV allergic reactions are mediated by T cells causing contact allergy with a local eczematous reaction with a latency of several hours to days. Some 3,500 triggers, often from occupational environment, are known; e. g., nickel, chromium, cobalt, fragrances, rubber, plastics, preservatives, dyes, neomycin, benzocaine, sulfonamides, quinidine, wool wax, perubalsam, eye therapeutics, light filter substances, disinfectants, pesticides, technical oils or plants. Diagnosis of contact allergy combines the history of cutaneous exposure with associated symptoms and patch testing, with detection of a late phase clinical reaction after 6 to 48, up to a maximum of 96 hours after antigen contact.

Acute Urticaria and Anaphylaxis: Differences and Similarities in Clinical Management

Acute urticaria is a common condition that presents with wheals and/or angioedema. However, these symptoms are also frequent in anaphylaxis, a life-threatening reaction that should be immediately diagnosed and treated. In both, mast cells play a central role in the physiopathology. Causes and triggers of acute urticaria and anaphylaxis are similar in general, but some peculiarities can be observed. The diagnostic approach may differ, accordingly to the condition, suspicious causes, age groups and regions. Adrenaline is the first-line treatment for anaphylaxis, but not for acute urticaria, where H1-antihistamines are the first choice. In this paper, we review the main aspects, similarities and differences regarding definitions, mechanisms, causes, diagnosis and treatment of acute urticaria and anaphylaxis.

Component-Resolved Evaluation of the Risk and Success of Immunotherapy in Bee Venom Allergic Patients

Venom immunotherapy (VIT) is the only efficient therapy for the Hymenoptera insect venom allergy. Immunotherapy with bee venom is encumbered with a higher risk of systemic side effects and/or therapeutic failures. The objective of the study was to assess if specific profiles of molecular IgE (Immunoglobulin E) responses are associated with an increased risk of systemic side effects and/or the treatment’s inefficacy. The study group numbered 64 bee venom allergic patients (BVA) who received venom immunotherapy modo ultra-rush (VIT-UR), (f/m: 32/32, mean age 43.4 ± 17.2). In total, 54.84% of them manifested allergic reactions of grades I-III (acc. to Mueller’s scale), while 48.66% manifested reactions of grade IV. In all the patients, IgE against bee venom extract, rApi m 1 and tryptase (sBT) were assessed. In 46 patients, assessments of IgE against rApi m 2, 3, 5, 10 were also performed. BVA patients manifesting cardiovascular symptoms (SYS IV0) showed higher levels of both sIgE-rApi m 5 (p = 0.03) and tryptase (p = 0.07) than patients with SYS I−III. Systemic adverse events during VIT with bee venom were more frequent in the induction phase than in the maintenance phase: 15.22% vs. 8.7%. In BVA patients who experienced systemic adverse events during VIT, higher concentrations of sIgE-rApi m 5 (p < 0.05), rApi m 1 (p = 0.009), and sBT (p = 0.019) were demonstrated. We conclude that higher levels of sIgE against rApi m 1, rApi m 5, and tryptase many constitute a potential marker of the severity of allergic reactions and therapeutic complications that can occur during VIT with bee venom.

Reducing the sting: Diagnosis and management of Hymenoptera venom allergy

ABSTRACT

Hymenoptera species include stinging insects such as wasps, hornets, bees, and fire ants. Allergic reaction to the venom of these insects is a common presenting complaint for patients in primary care and emergency medicine during warmer months. Patients' clinical presentations may vary, and clinicians must identify the type of reaction to determine treatment and follow-up plans. Treatment of patients allergic to Hymenoptera venom should be individualized based on risk factors, reaction type, and associated comorbidities. This article reviews common features of clinical presentation, diagnosis, and the current mainstays in management of Hymenoptera venom allergy.

Venom allergy and knowledge about anaphylaxis among beekeepers and their families

BACKGROUND

Beekeepers and their families are at an increased risk of life-threatening anaphylaxis due to recurrent bee-sting exposures.

OBJECTIVE

The aim of this study is to evaluate the demographic features, previous history of anaphylaxis among beekeepers and their family members, and their knowledge about the symptoms and management of anaphylaxis.

METHODS

A standardized questionnaire was administered to beekeepers during the 6th International Beekeeping and Pine Honey Congress held in 2018, in Mugla, Turkey. Additionally, food-service staff from restaurants were surveyed as an occupational control group about their knowledge about anaphylaxis.

RESULTS

Sixty-nine beekeepers (82.6% male, mean age 48.4±12.0 years) and 52 restaurant staff (46.2% male, mean age 40.5±10.0 years) completed the questionnaire. Awareness of the terms 'anaphylaxis' and 'epinephrine auto-injector' among the beekeepers were 55.1% and 30.4% and among the restaurant staff were 23.1% and 3.8%, respectively. Of the beekeepers, 74% were able to identify the potential symptoms of anaphylaxis among the given choices; 2.9% and 5.8% reported anaphylaxis related to bee-stings in themselves and in their family members, respectively. None of the restaurant staff had experienced or encountered anaphylaxis before but 3.8% of their family members had anaphylaxis and those reactions were induced by drugs.

CONCLUSION

It is essential that implementation of focused training programs about anaphylaxis symptoms and signs as well as practical instructions of when and how to use an epinephrine auto-injector will decrease preventable morbidities and mortalities due to bee-stings in this selected high-risk population of beekeepers and their family members, as well as other fieldworkers under risk.

The role of component-resolved diagnosis in Hymenoptera venom allergy

PURPOSE OF REVIEW

Component-resolved diagnostics (CRD) is a new tool aiming at detecting IgE-mediated sensitizations against individual, relevant allergens. Here, we discuss recent literature on molecular diagnosis in the field of Hymenoptera venom allergy (HVA) as well as CRD strengths and weaknesses.

RECENT FINDINGS

CRD, using single molecules or panels of allergens, may discriminate between primary sensitization and cross-reactivity in patients with double/multiple positivity in diagnostic tests with whole extracts, allowing the specialist to choose the most suitable venom for specific immunotherapy (VIT), avoiding unnecessary VIT and reducing the risk of side effects. Future availability of the cross-reactive recombinant pairs of allergens of different species may further increase the diagnostic performance. CRD may be useful in patients with negative allergy tests and a proven history of a previous systemic reaction, including those with mast cell disorders, who could benefit from VIT. In honeybee venom allergy, different sensitization profiles have been identified, which could be associated with a greater risk of VIT failure or treatment side effects.

SUMMARY

CRD is undoubtedly an innovative diagnostic method that leads to a more precise definition of the sensitization profile of the HVA patient. Together with a better knowledge of the molecular composition of different venom extracts, CRD may contribute to optimize patient-tailored therapy.

EAACI Allergen Immunotherapy User's Guide

Allergen immunotherapy is a cornerstone in the treatment of allergic children. The clinical efficiency relies on a well-defined immunologic mechanism promoting regulatory T cells and downplaying the immune response induced by allergens. Clinical indications have been well documented for respiratory allergy in the presence of rhinitis and/or allergic asthma, to pollens and dust mites. Patients who have had an anaphylactic reaction to hymenoptera venom are also good candidates for allergen immunotherapy. Administration of allergen is currently mostly either by subcutaneous injections or by sublingual administration. Both methods have been extensively studied and have pros and cons. Specifically in children, the choice of the method of administration according to the patient's profile is important. Although allergen immunotherapy is widely used, there is a need for improvement. More particularly, biomarkers for prediction of the success of the treatments are needed. The strength and efficiency of the immune response may also be boosted by the use of better adjuvants. Finally, novel formulations might be more efficient and might improve the patient's adherence to the treatment. This user's guide reviews current knowledge and aims to provide clinical guidance to healthcare professionals taking care of children undergoing allergen immunotherapy.

Apitoxin and Its Components against Cancer, Neurodegeneration and Rheumatoid Arthritis: Limitations and Possibilities

Natural products represent important sources for the discovery and design of novel drugs. Bee venom and its isolated components have been intensively studied with respect to their potential to counteract or ameliorate diverse human diseases. Despite extensive research and significant advances in recent years, multifactorial diseases such as cancer, rheumatoid arthritis and neurodegenerative diseases remain major healthcare issues at present. Although pure bee venom, apitoxin, is mostly described to mediate anti-inflammatory, anti-arthritic and neuroprotective effects, its primary component melittin may represent an anticancer therapeutic. In this review, we approach the possibilities and limitations of apitoxin and its components in the treatment of these multifactorial diseases. We further discuss the observed unspecific cytotoxicity of melittin that strongly restricts its therapeutic use and review interesting possibilities of a beneficial use by selectively targeting melittin to cancer cells.