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Honey Bee Stings PowerPoint Presentation

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Description : This medical presentation titled "Honey Bee Stings" is intended to make you understand sting reaction types, recognize responsible insects, understand risk factors, understand basic sting treatment, and understand when and how to immunize.

Tags : Honey Bee Stings, sting reaction types, insects, risk factors, sting treatment, immunize, Epidemiology

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Slide 1-

Honey Bee Stings
Slide 2-

Objectives Learn to : Understand sting reaction types Recognize responsible insects Understand risk factors Understand basic sting treatment Understand when and how to immunize
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Types of Illness from Bee Contact Propolis skin contact allergy Nasal allergy to hive dust and bee bodies Asthma and anaphylaxis from royal jelly Sting reactions: Local & Large Local allergy reactions Multiple sting Toxic reactions Systemic Anaphylacic reactions Cardiac reactions Bousquet J, Menardo JL, Michel FB. Allergy in beekeepers. Allergol Immunopathol (Madr). 1982;10(5):395-8.
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Epidemiology Insect sting allergy in Italy: Factory workers - 65% have been stung, 2.8% anaphylaxis. (similar to reported incidence in most temperate nations) Foresters - 68% have been stung, 4.5% anaphylaxis (not significantly higher) Incorvaia C, Senna G, Mauro M et al. Prevalence of allergic reactions to Hymenoptera stings in northern Italy. Eur Ann Allergy Clin Immunol. 2004;36(10):372-4.
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Epidemiology Insect sting allergy in Switzerland, Canton Bern (940,000 pop.): Annual incidence of severe anaphylaxis (with circulatory shock) was 6 / 100,000 Incorvaia C, Senna G, Mauro M et al. Prevalence of allergic reactions to Hymenoptera stings in northern Italy. Eur Ann Allergy Clin Immunol. 2004;36(10):372-4.
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U.S.A. General Population Insect Stings 27% sensitized to bee, wasp, or ant > 0.5 - 5% severe venom allergy > 40 deaths / year Neugut AI, Ghatak AAT, Miller RRL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. 2001;161(1):15-21. 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
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Stinging Insects Hymenoptera (membrane-winged insects) : Apids (honeybees and bumblebees) Vespids (yellow jackets, wasps, hornets, and paper wasps) Formicids (ants, fire ants) Most stings: honeybees and yellow jackets
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Apids (Bees)Risk of being Stung Domestic honeybees do not sting unless provoked Bumblebees rarely sting Africanized honeybees are hostile, aggressive, and sting in swarms
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This distinguishes honeybee stings from all other stings: bumblebees, wasps, and ants have no barbs Honeybee Stingeris Barbed
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Honeybee stings once this kills the bee
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Alarm pheromones evaporate from stings, attracting other bees to the victim Lewis,FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007;79:439-44
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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 Honeybee Sting Allergy Graft DF. Venom immunotherapy: when to start, when to stop Allergy Asthma Proc. 2000; 21:113-116
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Africanized Bee Stings Africanized bees and European bees have identical venoms Africanized bees are 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
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Africanized Bees 2009 Range
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Will Africanized Bees Replace European Bees? European (EHB) queens are not as good fighters Africanized (AHB) hives grow quicker, swarm more, and invade and replace EHB hives But…AHB hives do not thrive with over 55 inches of rain throughout the year, and AHB hives require more food, so won’t survive > 3 mo. without pollen & nectar supply (ie, Northern winter)
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Africanized BeesPotential Range
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Africanized Bee Advantages AHB hives grow quickly and are disease resistant AHB honey production is superior (Brazil went from 27th to 4th in global honey production after Africanization) AHB are Hybrids, not as aggressive as pure African Bees, but still good foragers
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Bumble Bee Stings Ground nesting, < 200 bees per nest Stinger not barbed: stings repeatedly Not easily irritated: stings uncommon
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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
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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 Hymenoptera: Formicids (Ants)
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Imported Fire Ant Range 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 At Risk: Pacific Northwest, Arizona, Virginia
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Venom Biochemistry Venom allergens are proteins or peptides : (Phospholipases, Acid Phosphatases, Hyaluronidases, Antigen-5 Neurotoxin) Venom toxins are mostly small mediator molecules : histamine, serotonin, kinins, acetylcholine, dopamine, norepinephrine
Slide 24-

Sting Risk Factors
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Sensitization Risk Frequent stings, especially less than 2 mo. apart, may sensitize Very frequent stings, over 50 / yr, usually desensitize 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
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Risk Factors for Serious Sting Reactions 1 Survey of 500 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.
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Beekeeper Stings 90% are stung/year; 55% get >100 stings Average of 58 stings/year (range: 0-1000) 4.4% - 6.5 % get serious reactions Higher Risks: having any kind of allergies, current allergy symptoms, fewer years as beekeeper, stings in spring season 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. 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
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Developing Bee Allergy in New Beekeepers 35 new beekeepers tested yearly for 5 years: 29% became venom sensitive most within 12 months, all by 18 months 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
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Predicting Risk of Serious Reaction in Beekeepers prior serious sting reaction allergic symptoms during hive work less than 8 years beekeeping high blood allergic venom antibodies 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.
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Consecutive Stings increase Anaphylaxis Risk 59% of serious reactions occur when there was a prior sting within 2 months (p=0.0001 – statistically 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.
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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.
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StingTreatment
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Immediate Action for all Bee Stings Rapidly remove venom sacs - envenomation is complete in one minute ! Use your HIVE TOOL to scrape it off ! 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.
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Types of Sting Reactions Immediate Allergic varies in severity Rare, Delayed Toxic (Non-Allergic) multiple stings required, always serious Rare, Immediate Cardiac Sting Reaction always serious Graft DF. Stinging insect hypersensitivity in children. Curr Opin Ped. 1996; 8:597-600
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Toxic Sting Reactions Organ toxicity: brain & nerves, blood clots, kidney or heart injury, multi-organ failure, and death 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.
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Kounis NG, Soufras GD, Lianas D, Patsouras N. After Administration of Intravenous Epinephrine for bee Sting-induced Anaphylaxis: Kounis Syndrome or Epinephrine Effect? Chin Med J (Engl). 2016 Feb 20; 129(4): 500–501 Scherbak D, Lazkani M, Sparacino N, Loli A. Kounis syndrome: a stinging case of ST elevation myocardial infarction. Heart Lung Circ. 2015 Apr;24(4):e48-50 Immediate Allergic Angina, which may progress to a Heart Attack Requires treatment of both the sting allergy, and the poor blood flow to the heart Must go to hospital for treatment Cardiac Sting Reaction
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Severity of Allergic Reactionsto Bee Stings Local: pain, redness at site Large Local: swelling of extremity Systemic: generalized, involves any symptoms at a remote site from the sting. These may quickly be life threatening
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Immediate TherapyLocal Reactions 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.
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Immediate TherapyLarge Local Reactions 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.
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Immediate TherapySystemic Anaphylaxis Inject epinephrine & treat for anaphylaxis. ALWAYS 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.
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Deciding to Observe a Sting Remove stingers Calmly call for help. It’s wise to have a friend or relative with you, while you wait to see how you will do Take any oral antihistamine
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Deciding to use Epinephrine Do you have any symptoms distant from the sting site? YES Do you have any breathing, swallowing, or voice difficulty? YES Do you feel like you could die? YES Use Epinephrine AND call 911
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Systemic Anaphylaxis Treat immediately – time matters ! USE epinephrine self-injector - easy, safe, quick Inject into muscle. Count 15 sec. to allow spring to inject the medicine Be ready to Re-Treat. Epinephrine may only last 5-10 minutes
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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.
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How to UseEpi-Pen Caution after removing safety cap - don’t inject hand Swing hard Inject through your clothes Hold against leg & count slowly to 15
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After Giving Epinephrine Always CALL 911 If patient has asthma, USE THEIR INHALERS If available, give any oral antihistamine Keep giving Epinephrine, as often as needed to control symptoms
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Therapy for Severe orMultiple Insect Stings Give Glucocorticoids Consider Vasopressin, Heparin, Glucagon Treat shock : fluids, pressors Be prepared to intubate, suction, ventilate Transport immediately by ambulance Consider dialysis and plasmapheresis to remove inflammatory mediators & venom components Diaz-Sanchez CL, Lifshitz-Guinzberg A, Ignacio-Ibarra G, et al. Survival after massive (>2000) Africanized honeybee stings. Arch Intern Med. 1998;158:925-7
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Mastocytosis Urticaria pigmentosa - mastocytosis is a major risk factor for fatal sting Dx is often unexpected (7% of sting pts) Dx by high blood tryptase levels Immunotherapy essential, but not fully protective Consider lifetime immunotherapy Consider drug prophylaxis (H1 & leukotriene blockade) Haeberli G, Brönnimann M, Hunziker T, Müller U. Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Clin Exp Allergy. 2003 Sep;33(9):1216-20.
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Mastocytosis References Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Haeberli G, Bronnimann M, Hunziker T, Muller U. Clin Exp Allergy . 2003;33:1216-20 Constitutively raised serum concentrations of mast-cell tryptase and severe anaphylactic reactions to Hymenoptera stings. Ludolph-Hauser D, Rueff F, Fries C, Schopf P, Przybilla B. Lancet . 2001;357:361-2 Krishna MT, Fearby S, Annila I, Frew A. Hymenoptera stings and serum tryptase. Lancet. 2001 May;357:1527-8 Mastocytosis associated with severe wasp sting anaphylaxis detected by elevated serum mast cell tryptase levels. Biedermann T, Rueff F, Sander CA, Przybilla B. Br J Dermatol . 1999;141:1110-2 Fatal anaphylaxis after a yellow jacket sting, despite venom immunotherapy, in two patients with mastocytosis. Oude Elberink JN, de Monchy JG, Kors JW, et al. J Allergy Clin Immunol . 1997;99:153-4
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Clinical History - helps with hospital 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
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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 What Insect Was it ?
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Venom Cross-Reactivity Strong cross-reactivity occurs between : Bumblebees and Honeybees (not total) Yellow Jackets & Hornets Paper Wasps (Polistes sp.) Fire ants (Solenopsis sp.) Cross-reactivity between different families is not clinically useful Bosquet J, Muller UR, Drebord S, et al. Immunotherapy with Hymenoptera venoms. Allergy 1987; 42:401-413
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History of Skin Testsfor Stinging Insects Braun 1925, Benson 1930 Used honeybee abdomen, venom sac, and venom extracts to skin test and immunize Schwartz 1965 showed frequency of positive skin tests to whole body extracts was no greater than in un-stung, pollen-allergic patients therefore, venom testing is preferred
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Venom extracts for bees & wasps available since 1978 Venom proved superior to whole body extracts in preventing reactions Exception: only whole body extracts available for fire ants - shown to be effective History of Venom Extracts for Stinging Insects
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WhichInsects 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.
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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
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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
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If blood test is negative, and suspicion of allergic reaction is high if immunotherapy is needed, skin test must precede beginning treatment Why to do Skin Tests
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most sensitive method Venoms are standardized based on Hyaluronidase content : Honeybee, Yellow Jacket, Yellow Hornet, Bald-faced Hornet, Polistes Wasps Bumblebee venom available only in Europe Skin Test Details
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Bee-Venom Allergywithout 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.
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After a Reaction is Over
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Testing for Bee Venom Allergy Blood testing 4-6 weeks after sting Evaluate results and consider reaction severity, progression in severity on serial stings, likelihood of another sting, and other medical conditions (like heart disease) Consider skin testing
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Recommended Testing Sequence : first do In Vitro tests then EXACTLY follow instructions in venom package insert single prick test at 1mg/ml to screen for extreme sensitivity prepare 1:10 dilutions (1ng/ml to 1mg/ml) do IDT with 1:10 dilutions until first positive wheal. DO NOT USE confirming wheal Diagnosis ofStinging Insect Allergy
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Insect Avoidance Extra care in Picnic/Garden areas Orchards, flowers, pools & water sources Wear shoes, long sleeves, pants, gloves Avoid fragrances, bright colors Use protective suit, veil, & gloves when working with bees – every time ! Management of ProvenSting Allergy
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Epinephrine kits Kits must be with you to be useful epinephrine stability is poor with oxygen, light, & heat. Do not keep in hot car ! ( check expiration and replace kits when needed ) Practice injector use Always call 911 after epinephrine Management ofSting Allergy
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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 Management ofSting Allergy
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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
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Hornet / Yellow JacketTreatment Yellow Jacket sting often causes cross-reactions with both Hornet species If Yellow Jacket positively identified, treat with Yellow Jacket venom alone If not positively identified, treat with Mixed Vespid venom (1:1:1 mix of Yellow Jacket, Yellow Hornet, Bald-faced Hornet)
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Polistes (Paper Wasp) Treatment Weak cross-reactions with Yellow Jackets & Hornets If positive test, treat with Polistes Wasp venom (unless positive Yellow Jacket ID was made)
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Bumblebee Treatment Honeybee venom may not completely protect, since bumblebee contains some unique antigens If minimally exposed to bumblebees, treat with honeybee venom If employed where bumblebees are being used as pollenators, treat with bumblebee venom 1. de Groot H. Allergy to bumblebees. Curr Opin Allergy Clin Immunol. 2006;6(4):294-7. 2. Stern A, Wuthrich B, Mullner G. Successful treatment of occupational allergy to bumblebee venom after failure with Honeybee venom extract. Allergy 2000; 55: 88-91
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Fire Ant Treatment Use available whole body extract. Switch to venom, when that becomes available Freeman TM, Hylander R, Ortiz A, Martin ME. Imported fire ant immunotherapy: effectiveness of whole body extracts. J allergy Clin Immunol 1992; 90:210-215
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Fire Ant Treatment Asian and Australian fire ants are distinct species, and require specific immunotherapy that is different from that for American fire ants (Solenopsis sp.)
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Immunotherapy to Prevent Toxic Sting Reactions Immunotherapy may prevent serum sickness Immunotherapy may reduce Fire Ant sting necrosis Effects with mass bee stings are unknown Reisman RE. Stinging Insect Allergy. Med Clin NA 1992; 76:883-894
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Immunotherapy Escalation Schedules vary from slow buildup (weeks) to rapid (hours to days) Rapid methods have higher risk of anaphylaxis Use rapid method only when patient is very likely to be re-stung in near future Use strict anaphylaxis precautions if doing rapid therapy Venom Immunotherapy
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Modified Rapid Schedule Day 1 0.1mg, 1mg, 3mg, given every 20 min. Week 2 10 mg Week 3 20 mg Week 4 40 mg Week 5 70 mg Week 6 100 mg Maintenance dose Continue weekly injections to 16 weeks, then continue monthly injections for 5 years Venom Immunotherapy Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258:2881-2885
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High DoseVenom Immunotherapy Up to 20% of patients are not protected by 100 g venom doses 150 - 400 g may be required in these patients Mixed vespid therapy is 300 g; bee or single wasp therapy is more likely to need increase Evaluate patients requiring large venom doses by serum tryptase for systemic mastocytosis Rueff F, Wenderroth A, Przybilla B. Patients still reacting to a sting challenge while receiving conventional Hymenoptera venom immunotherapy are protected by increased venom doses. J Allergy Clin Immunol. 2001; 108:1027-32
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Expected Lab Results of Venom Immunotherapy Early IgE increase, peaks at 8-12 weeks Subsequent steady IgE decrease over years Increasing IgG until 2-4 months Subsequent plateau or slight decline Skin & IgE tests may become negative Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258:2881-2885
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Measurement of Venom IgG IgG > 3 mg / ml, or else immunotherapy dose must be increased (to 200 mg or more) IgG > 5 mg / ml is usually protective, but, some lower levels protect, and rarely, high levels do not 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
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Treatment effectiveness is 97% (Wasps) or >80% (Honeybees) < 20% have mild reactions due to treatment Rare patients (0.7 %) require epinephrine during therapy Immunotherapy Results 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
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Immunotherapy Results 6.5 years after beginning venom treatment: 41% had been re-stung >90% had improved quality of life: less fear, anxiety, depression, and fewer changes in lifestyle because of treatment 1. Findeis S, Craig T. The relationship between insect sting allergy treatment and patient anxiety and depression. Allergy Asthma Proc. 2014 May-Jun;35(3):260-4 2. 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.
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Immunotherapy Results immunotherapy patients, after at least 3 years of treatment. 55% were re-stung, and 92% had only local reactions 8% had milder systemic reactions than before treatment Hafner T, DuBuske L, Kosnik M. Long-term efficacy of venom immunotherapy. Ann Allergy Asthma Immunol. 2008 100(2):162-5.
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Benefits of Immunotherapyfor Beekeepers Beekeepers vs non-beekeepers: no difference in immunotherapy results beekeepers had fewer reactions during treatment 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.
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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.
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Checking on Treatment Effectiveness
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Blood Test of Immunity If protective immunity is occurring : IgE allergic antibodies decrease IgG protective antibodies increase Blood may be checked before stopping treatment (usually at 5 years) Higher venom doses can be used if standard doses do not work 1. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hyper-sensitivity. JAMA 1987; 258:2881-2885 2. Bosquet J, Muller UR, Drebord S, et al. Immunotherapy with Hymenoptera venoms. Allergy 1987; 42:401-413
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In rare patients, it is impossible to increase the venom treatment dose high enough to produce good immunity, without triggering unacceptable reactions Most people with this problem can be helped with Xolair anti-IgE treatment
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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..
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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
Slide 89-

Whole body fire ant immunotherapy is effective (2% reactions when stung, vs 100% in non-immunized patients) But, standard fire ant immunotherapy takes months, during which time re-sting may occur Alternately, a rush schedule, over 2 days, had only a 5.2% anaphylaxis rate, and should be considered for patients at high risk of re-sting Fire Ant Immunotherapy Freeman TM, Hylander R, Ortiz A, Martin ME. Imported fire ant immunotherapy: effectiveness of whole body extracts. J Allergy Clin Immunol 1992;90:210-5 Tankersley MS, Walker RL, Butler WK, et al. Safety and efficacy of an imported fire ant rush immunotherapy protocol with and without prophylactic treatment. J Allergy Clin Immunol 2002;109:556-62
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High risk persons may not be able to stop + anaphylactic shock + systemic reactions to venom therapy + occupational exposure + Honeybee sensitive + Systemic mastocytosis Avg. 10% risk after 5 years Rx (8-16%) When Not to Stop Immunotherapy 1. Graft DF. Venom immunotherapy: when to start, when to stop Allergy Asthma Proc. 2000; 21:113-116 2. Muller UR. Duration of venom immunotherapy. J Allergy Clin Immunol. 1997; 95:271-272
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Summary Avoidance techniques should always be used (WEAR YOUR GEAR) If allergic, epinephrine injector should always be with you Accurate diagnosis is critical Immunotherapy is highly effective, but treatment failures still can occur
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Happy, Safe, Beekeeping !
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