Stinging Insect Allergy
Barnstable County
Beekeepers Association
April 12, 2011
Bruce R. Gordon, MD, FACS, FAAOA
Harvard Clinical Instructor
President, American Academy of Otolaryngic
Allergy, 2002-2003
Objectives
Learn to :
• Understand sting reaction types
• Recognize responsible insects
• Understand risk factors
• Understand basic treatment of stings
• Understand when and how to immunize
• Understand when to stop immunotherapy
Type of Reactions to Bees
• Contact allergy to propolis
• Respiratory allergy to hive dust and bee
bodies
• Asthma and anaphylaxis from royal jelly
• Sting reactions:
– Toxic reactions
– Local reactions
– Systemic Anaphylacic reactions
Bousquet J, Menardo JL, Michel FB. Allergy in beekeepers.
Allergol Immunopathol (Madr). 1982;10(5):395-8.
Epidemiology
• 26.5% U.S. prevalence of venom sensitization
(27.1% in Germany)
• > 0.5 to 5% U.S. Severe insect sting allergy
• > 40 deaths / year U.S. from insect stings
– (does not include suspicious sudden deaths)
1.
Neugut AI, Ghatak AAT, Miller RRL. Anaphylaxis in the United States: an investigation into
its epidemiology. Arch Intern Med. 2001;161(1):15-21.
2. Schäfer TT, Przybilla BB. IgE antibodies to Hymenoptera venoms in the serum are common
in the general population and are related to indications of atopy. Allergy. 1996;51(6):372-7.
3. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA
1987; 258:2881-2885
Sensitization Risk
from Stings
• Frequent stings, especially < 2 mo.
apart, sensitize
• Very frequent stings, > 50 / yr,
desensitize (beekeepers)
Pucci S, Antonicelli L, Bilo MB, Garritani MS, Bonifazi F.
Shortness of interval between two stings as risk factor for
developing Hymenoptera venom allergy. Allergy. 1994;49:894-6
Types of Stinging Insects
Stinging insects are order Hymenoptera
(membrane-winged insects)
• Apids (honeybees and bumblebees)
• Vespids (yellow jackets, wasps,
hornets, and paper wasps)
• Formicids (ants, fire ants)
Hymenoptera: Apids
(Bees)
Risk of being Stung
• Domestic honeybees do not sting unless provoked
• Bumblebees are not aggressive & rarely sting, but
use in greenhouses increases exposure
• Africanized hybrid honeybees, common in Mexico
and South, are hostile, aggressive, and swarm
Africanized Bees 2009 Range
Honeybee
Stinger
is Barbed
• Bees leave their barbed stinger and
venom sac implanted in their victim
• This distinguishes honeybee stings from
all other stings: bumblebees, wasps, and
ants have no barbs
Lewis,FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007;79:439-44
Honeybee Sting Allergy
Honeybee venom is very sensitizing
–More likely to react on re-sting
–More likely to react during
immunotherapy treatments
–Less likely to be protected by
immunotherapy
–Less likely to stop immunotherapy
Graft DF. Venom immunotherapy: when to start, when to stop
Allergy Asthma Proc. 2000; 21:113-116
Africanized Bee Stings
• Africanized bees and domestic bees
have identical venoms
• Africanized bees are much more
dangerous due to easy arousal,
aggressive stinging, mass stings, and
persistent pursuit of the victim
Lewis,FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007;79:439-44
Bumble Bee
Stings
• Ground nesting, < 200 bees per nest
• Stinger not barbed: stings repeatedly
• Not easily irritated: stings uncommon
Hymenoptera:
Vespids (Wasps)
• Yellow Jackets: ground nesting; very
aggressive & swarm - stings cause skin
infection
• Hornets, Wasps, and Paper Wasps : aerial
nesting - in trees, roof overhangs, shutters,
under shingles, in attics; not aggressive
unless disturbed
Hymenoptera:
Formicids (Ants)
Imported Fire Ants found in SE
and Gulf coast; will spread much
further north & west from global warming
Ants bite, and deliver multiple stings in
circular pattern; aggressive & swarm
- attacks 6 - 60% of people living in an area
during each year.
Harvester Ants (native fire ants) found in SW;
stings painful, but fatalities rare
Imported Fire Ant Range
At Risk: Pacific Northwest, Arizona, Virginia
Tracy JM, Demain JG, Quinn JM et al. The natural history of exposure to the
imported fire ant (Solenopsis invicta). J Allergy Clin Immunol 1995; 95:824-828
Sting Risk Factors
Risk Factors for Serious
Sting Reactions 1
Survey of 494 beekeepers:
• 90% stung/year, 55% had >100 stings
• 6.5% had serious reactions
• Risks: having any kind of allergies,
especially asthma, food allergies, or multiple
kinds of allergies
Celikel S, Karakaya G, Yurtsever N et al. Bee and bee products allergy in Turkish beekeepers:
determination of risk factors for systemic reactions.
Allergol Immunopathol (Madr). 2006;34(5):180-4.
Risk Factors for Serious
Sting Reactions 2
Survey of 1053 beekeepers:
• annual stings/person 0-1000, average 58
• 4.4% had serious reactions
• Risks: current allergy symptoms, having
allergies, years as beekeeper, stings in spring
Münstedt K, Hellner M, Winter D, et al. Allergy to bee venom in beekeepers in Germany.
J Investig Allergol Clin Immunol. 2008;18(2):100-5
Developing Bee Allergy in
New Beekeepers
35 new beekeepers tested for 5 years:
• 29% became venom sensitive
• most within 12 months, all by 18 months
• number of stings and presence of other
allergies had no effect on developing sting
allergy
Kalogeromitros D, Makris M, Gregoriou S et al. Pattern of sensitization to honeybee
venom in beekeepers: a 5-year prospective study. Allergy Asthma Proc. 2006;27(5):383-7
Predicting Risk of Serious
Reaction in Beekeepers
78 beekeepers studied before being stung
Risks are:
• pre-exposure high IgE blood test > 1 ku/L
• allergic nasal, eye, or lung symptoms
during hive work
• less than 8 years beekeeping
• prior serious sting reaction
Annila IT, Annila PA, Mörsky P. Risk assessment in determining systemic reactivity
to honeybee stings in beekeepers. Ann Allergy Asthma Immunol. 1997;78(5):473-7.
Consecutive Stings increase
Anaphylaxis Risk
120 sting-allergic persons:
• 59% of serious reactions occur when
there was a prior sting within 2 months
(p=0.0001 - highly significant)
Pucci S, Antonicelli L, Bilò MB et al. Shortness of interval between two stings as risk
factor for developing Hymenoptera venom allergy. Allergy. 1994;49(10):894-6.
Fewer Stings increase
Anaphylaxis Risk
176 sting-allergic beekeepers:
• reaction risk is inversely correlated
with annual number of stings
Bousquet J, Ménardo JL, Aznar R et al. Clinical and immunologic survey in beekeepers
in relation to their sensitization. J Allergy Clin Immunol. 1984;73(3):332-40.
Types of Sting Reactions
• Immediate Allergic
– Local, Large Local, Systemic
• Delayed Toxic (Non-Allergic)
– Serum sickness, CNS demyelination,
vascular thrombosis, glomerulonephritis,
myocarditis, multi-organ failure, and death
– Multiple stings required :
LD50 (honeybee) > 500 stings
Graft DF. Stinging insect hypersensitivity in children.
Curr Opin Ped. 1996; 8:597-600
Immediate
Therapy
for all
BeeStings
• Rapidly remove all bee venom sacs envenomation is complete in one minute !
• Use your HIVE TOOL !
Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from
honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.
Toxic Sting Reactions
• Honeybees (especially Africanized) or Wasps
(yellowjackets and hornets)
• Without treatment, > 20-200 wasp stings
or > 150-1000 bee stings can be fatal
• Symptoms may not appear for hours to
several days
• Go to the hospital immediately for any mass
sting (call 911 !!!)
Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps.
West J Med. 1999;170(4):223-7.
Allergic Reactions
to Insect Stings
1. Local: pain, redness at site
2. Large Local: swelling of extremity
3. Systemic: generalized, involves any
symptoms at a remote site from the
sting. These may quickly be life
threatening.
Immediate Therapy
for Stings
• Local reaction: ice, antihistamine
Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from
honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.
Immediate Therapy
for Stings
• Large Local reaction: ice, antihistamine,
prescription prednisone
Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from
honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.
Immediate Therapy
for Stings
• Systemic reactions: give epinephrine & treat
for anaphylaxis. Call 911 !!!
Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from
honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.
Systemic Reactions
• Treat immediately !
• If you think of epinephrine, USE IT !
• Epinephrine 1:1000 (0.01ml/kg)
= 0.3 ml adult, 0.15 ml child.
Inject into muscle !
• Be ready to Re-Treat. Epinephrine
may only last 5-10 minutes.
Systemic Reactions
• Epinephrine is required more than
once in 35% of anaphylaxis cases
• Most insurance companies cover
dual packs of epinephrine
injectors.
Buy them !
Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine
administration for anaphylaxis: how many doses are needed?
Allergy Asthma Proc. 1999;20(6):383-6.
Epinephrine
Use
• Caution after
removing safety cap
- don’t inject hand
• Swing hard
• Inject right
through your clothes
• Hold against leg &
count slowly to 10
After Giving Epinephrine
• CALL 911
• Keep giving Epinephrine, as often
as needed to control symptoms
• If patient has asthma, USE THEIR
INHALERS
• If available, give oral
Antihistamine and Oxygen
Facts to Remember
Clinical History - helps with treatment
Important to Identify:
• what kind of insect
• type of reaction
• severity of reaction
• ? progression of this reaction over time
• ? worse compared to last sting
What Insect Was it ?
• Winged / flying eliminates Fire Ants
• Stinger left in skin : Honeybee
• Nest location : ground favors Yellow
Jacket (bumble bee less common)
• Large size: favors Hornet
• Narrow waist: not a bee or bumblebee
Which
Insects to Test 1
• About 90% of stings are from Wasps
• Always test Yellow Jacket
(most aggressive, most likely to sting)
• If Wasp or Hornet is likely, test all local
species
• If Africanized bees are local, test Honeybee
Pérez-Pimiento AJ, González-Sánchez LA, Prieto-Lastra L, et al. Anaphylaxis to
hymenoptera sting: study of 113 patients. Med Clin (Barc). 2005;125(11):417-20.
Which Insects to Test 2
• If stinger found, test Honeybee
• When unsure, test Honeybee & Yellow
Jacket
• If stung by Bumblebee (large bee), test
for Honeybee and Bumblebee
• If poor history, test all local species
Why to do In Vitro (Blood) Tests
• IgE:
– To identify culprit insect ( may be falsely
negative in 15-20%)
– To determine degree of sensitivity
– To differentiate toxic and allergic Rxn
– For Safety, prior to Skin Testing
• IgG :
– To check progress of desensitization
Reisman RE. Stinging Insect Allergy. Med Clin NA 1992; 76:883-894
Why to do Skin Tests
• If blood test is negative, and suspicion of
allergic reaction is high
• if immunotherapy is needed, skin test
must precede beginning treatment
Bee-Venom Allergy
without positive Tests
• In very rare patients with classic bee
sting anaphylaxis history, blood tests and
skin tests may both be negative.
• If an in-hospital sting challenge is
positive, immunotherapy is indicated.
Zidarn M, Kosnik M, Drinovec I. Anaphylaxis after Hymenoptera sting without detectable
specific IgE. Acta Dermatovenerol Alp Panonica Adriat. 2007 ;16(1):31-3.
Management of Proven
Stinging Insect Allergy
Insect Avoidance
– Caution during outdoor activities
• Look for nests on ground, roofs
– Extra care in Picnic areas
• Orchards, trash containers, soda cans, fruit
– Wear shoes, long sleeves, pants, gloves
– Avoid fragrances, bright colors
– Use protective suit, veil, & gloves when
working with bees
Management of
Stinging Insect
Allergy
• Epinephrine kits
– Kits must be with you to be useful
• epinephrine stability is poor with oxygen,
light, & heat ( replace kits as needed )
– Practice epinephrine use
– Always call 911 after epinephrine
• Antihistamines & corticosteroids are
OK to use AFTER epinephrine
Management of
Stinging Insect Allergy
Venom Immunotherapy
(Allergy Shots) - should be
considered in all persons who:
• have a positive history of one or
more Systemic Reactions to stings
• have a positive diagnostic test
• are likely to be re-stung
Who Needs Immunotherapy ?
Only 25 - 50% of patients repeat Systemic
Reactions when re-stung
• risk increases with repeat stings,
especially if close together in time
• higher risk for occupational exposure
• higher risk for asthmatics
• highest risk if Circulatory Shock occurs
• clinical judgement required
Immunotherapy Results
• Treatment effectiveness is 97% (Wasps)
or 80% (Honeybees)
• About 20% have mild reactions due to
treatment, usually early in therapy
• Rare patients (0.7 %) require
epinephrine during therapy
1. Mosbech H, Muller U. Side-effects of insect venom immunotherapy:
results from an EAACI multicenter study. Allergy 2000; 55:1005-1010
2. Muller UR. Duration of venom immunotherapy. J Allergy Clin Immunol.
1997; 95:271-272
Immunotherapy Results
146 sting immunotherapy cases, at 6.5
years after beginning treatment.
• High Risk of re-sting (41%)
• Most had improved quality of life
(90% had less fear and fewer changes
in lifestyle on immunotherapy)
Roesch A, Boerzsoenyi J, Babilas P. et al. Outcome survey of insect venom allergic
patients with venom immunotherapy in a rural population.
J Dtsch Dermatol Ges. 2008;6(4):292-7.
Immunotherapy Results
181 sting immunotherapy cases, 1 - 27
years after at least 3 years of treatment.
• High Risk of re-sting (55%)
• Most had only local reactions (92%)
• Systemic reactions (8% ) were milder
than before treatment
Hafner T, DuBuske L, Kosnik M. Long-term efficacy of venom immunotherapy.
Ann Allergy Asthma Immunol. 2008 100(2):162-5.
Benefits of Immunotherapy
for Beekeepers
459 bee-allergic patients:
• 14% were beekeepers, and 10% were
beekeeper’s family members
• beekeepers vs non-beekeepers: there
was no difference in results of
immunotherapy
• beekeepers had less problems with IT
• most beekeepers continued beekeeping
with immunotherapy protection
Eich-Wanger C, Müller UR. Bee sting allergy in beekeepers.
Clin Exp Allergy. 1998;28(10):1292-8.
Repeated Stings may increase
Reaction Severity
40 sting allergy immunotherapy cases,
after at least 3 years of treatment, were
then re-stung more than once.
• 83% remained desensitized
• 17% had progressively more severe
reactions with each subsequent sting (like
people never treated with immunotherapy)
Hafner T, DuBuske L, Kosnik M. Long-term efficacy of venom immunotherapy.
Ann Allergy Asthma Immunol. 2008 100(2):162-5.
Lab Check on Immunity
IgG and IgE can be measured in blood.
• If protective immunity is occurring:
– IgE should decrease
– IgG should increase
• Higher venom doses can be used if
standard doses do not work
1. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258:2881-2885
2. Bosquet J, Muller UR, Drebord S, et al. Immunotherapy with Hymenoptera
venoms. Allergy 1987; 42:401-413
Difficulty with Immunization
• In rare patients, it is impossible to
increase the venom dose high enough
to produce good immunity, without
triggering unacceptable reactions
• Most people with this problem can
now be helped with anti-IgE
Anti-IgE and Immunotherapy
Where immunotherapy reactions
prevented administering adequate
venom doses, adding anti-IgE
(omalizumab, Xolair) resulted in
success in 7 reported cases
Galera C, Soohun N, Zankar N.et al. Severe anaphylaxis to bee venom immunotherapy:
efficacy of pretreatment and concurrent treatment with omalizumab.
J Investig Allergol Clin Immunol. 2009;19(3):225-9..
When to Stop Bee Immunotherapy
• After 5 years, before stopping maintenance
injections, measure blood IgE and IgG
– IgE should drop to 0
– IgG should be > 5 mg / ml
• How likely is this person to be restung ?
• How severe was the last sting reaction ?
• Are there any treatment side effects ?
• Weigh the pros and cons carefully
Summary
• Avoidance techniques should always
be employed
• Emergency epinephrine should
always be with you
• Accurate diagnosis is critical
• Immunotherapy is highly effective,
but treatment failures still can occur
Happy, Safe, Beekeeping !