Insect Sting Allergy - PDF document

Insect Sting Allergy Dean Tey i All e r g i st & Imm u n o l i st aedatcegst&uoogst Monday 17 June 2010 InsectStingAllergy Insect 1.E pgy 2.Aetiology (meet the in

sects)3.Clinical presentation 4.Risk of future systemic reactions5.Investigations 6.Managementa)Prevention Localreactions c)Systemic reactions ) Venom immunotherap y ) y

Epidemiology Epidemiology • –In Australia, approximately 1200 admissions peryearattributedtowardshornetwaspor per bee stings (2002-2005)• –In Australia, approxi

mately 2 cases per year (20casesbetween1997 - –I�n USA, 50 cases per year. 1.Bradley C. Australian Institute of Health and Welfare; 2008. Catalogno. INJCAT

110.2.Liew et al; JACI 2009;123:434-42.3.Barnard JH. JACI 1973;52:259-64. InsectStingAllergy Insect 1.E pgy 2.Aetiology (meet the insects)3.Clinical presentation 4.R

isk of future systemic reactions5.Investigations 6.Managementa)Prevention Localreactions c)Systemic reactions ) Venom immunotherap y ) y Yellow jackets •Major allergen Ve

sv 5 Yellowandblackincolour Yellow •Smooth thorax and abdomen•Ill tempered•Nests concealed in the ground or behind iditiill s ng or re t a i n i ng wa ll •Scaven

ge for rotting fruit (found near garbage cans, dumpsters and orchards)•Most common cause of insect stin g JkJAt g reactions because they are disturbed when gardening an

d lawn mowing J ac J t •Colour is black, or red-and-black•Yellow/orange legs, antennae and mandibles mandibles •Most common in Tasmania. In Victoria, •Have a characteris

tic jumping motion hittd w h en ag it a t e d •Highly territorial and may fight with ants Photograph courtesy Alex Wild. ://www.m Cross-reactivit reactivit ORDER:HYMENO

PTERA have limited FamilyGenus/Species Apis(Honeybee) mellifera (Europeanhoneybee) and the vespid venoms 1 mellifera honeybee) •Bombus(Bumblebee)Vespidiae (Wasps) •Vesp

ulaand Dolichovespula(Yellow jackets or ‘ wasps ’ ) (Wasps) wasps ) •Vespulagermanica(European/German Wasp)•Vespulavulgaris(Common wasp) •Vespa(Hornets)•Polistes(Paper

wasps) (At) •Myrmecia(Bullants) ill (Jkjt) t s ) • M j umper an t) 1. Golden DBK. JACI 2005;115:439-47. InsectStingAllergy Insect 1.E pgy 2.Aetiology (meet the insect

s)3.Clinical presentation 4.Risk of future systemic reactions5.Investigations 6.Managementa)Prevention Localreactions c)Systemic reactions ) Venom immunotherap y ) y Hist

ory – importantaspects History •Current sting –Identify the particular insect involved•Single (bee) versus multiple stings (wasp)•Presence of sting (honeybee or Yello

w jacket) Tiffi – Ti me o f onset o f react –Signs of anaphylaxis (note: hoarse voice, coughing)•Previous stings –Severity of previous reactions–Number of stings h e g

i espec a Oteaegesespecayasta •Social history–Risk of future sting? E.g. beekeepers – Timetonearesthospital? – Time 1.Golden DBK. Immunol Allergy Clin N Am 2007;17:

261-272 Riskofsystemicreaction Risk • A s y m p atients with a p ositive yppp diagnostic venom test (skin test or sIgE)–15-25% of adults have a positive venom tes

t Thisiscommonlytransientwith12%ofsubjects – becoming negative every year–The risk of systemic reaction to a subsequent ti17%(11/65bjt)dt0% s ng was 17% (11/6

5 su bj ec ) , compare d t 0% in patients with a negative skin test (0/160) – A n ex p lanation ma y be that a variable p ro pypp of these IgEantibodies are directed

against the CHO determinants that cross-react with foods 1.Golden et al. JAMA 1989;262:240-2442.Golden et al. JACI 1997;100:760-6.3.Hemmer et al. JACI 2001;108:1045-52.

Investigations Investigations • Whotoinvestigate? –Diagnostic tests are indicated when the risk futureofanaphylaxisisjudgedtobehigh(ie future . e T

hesearesubjectswhereimmunotherapyis being considered InsectStingAllergy Insect 1.E pgy 2.Aetiology (meet the insects)3.Clinical presentation 4.Risk of future

systemic reactions5.Investigations 6.Managementa)Prevention Localreactions c)Systemic reactions ) Venom immunotherap y ) y Investigations Investigations • –Insect venom

skin test InsectvenomspecificIgE – Insect –Sting challenge • Consideredimpracticalandunethical 12 • Considered 1 , 2 •Even when sting challenge causes no rea

ction there remains a 15-20% chance of a s y stemic reaction from a subsequent sting3 1.vanderLindenet al. JACI 1994;94:151-92.ReismanRE. JACI 1993;91:11003.Franken et a

l. JACI 1994;93:431-6 Investigations Investigations • Insectvenomskintest –The preferred diagnostic method Highdegreeofsensitivity�(65%)andproven – High

UseincomplementwithvenomsIgE •15-20% with positive skin tests have negative g E •5-10% with negative skin tests have positive sIgE 1.Hamilton RG. Cur r

Opin llergy ClinImmunol2004;4:297-3062.Allergen immunotherapy: a practice parameter second update 2007;JACI;120:S25-S85.3.Sobotkaet al. J Immunol1978;121:2477-844.Golden

et al. JAMA 1989;262:240-4. InsectStingAllergy Insect 1.E pgy 2.Aetiology (meet the insects)3.Clinical presentation 4.Risk of future systemic reactions5.Investigatio

ns 6.Managementa)Prevention Localreactions c)Systemic reactions ) Venom immunotherap y ) y Management Management 2 Localreactions 2 . –Acute management OralH1 antihista

mines:usesecondgeneration - : •Oral corticosteroids: consider if oedema is •Ice pack and simple analgesia Atibitilid • A n o cs are rare l y requ i re –Reassure

and explain natural history of 10% chanceoffuturesystemicallergicreaction chance 1.Moffitt et al. JACI 2004;114;869-86.2.Severino et al. Current Opinion in Al

lergy and Clinical Immunology 2009;9:334-337 VenomImmunotherapy Venom • Aims Aims –Indicated in patients with positive diagnostic testandsystemicreactiontoasting 1

a –Ultimate goal is to prevent fatal anaphylaxis 1.Moffitt et al. JACI 2004;114;869-86.2.Golden DBK. JACI 2005;115:439-47 VenomImmunotherapy Venom Efficacy Eff

icacy –Without VIT, risk of anaphylaxis is 40-60% allergic reaction – WithVITriskof reaction reduced to 5%()t15% 5% ( t 15% 1.Golden DBK. JACI 2005;115:439-47.2.Ler

ch et al. JACI1998;101:606-12. VenomImmunotherapy Venom • Riskfactorsforrelapse 1.More severe allergic reaction on history 2 Honeybeeallergy 2 . 3.Systemic reac

tion during VIT 4 Lessthan5yearsofVIT 4 . 5 1 MulleretalJACI1992;89:529 4 etalJACI1998;101:606 1 . - 2.Golden et al. JACI 1998;101:298-3053.Golden et al. JA

CI 2000;105:385-90 4 . - 5.Reismanet al. JACI 1993;92:831-66.Keating et al. JACI 1991;88:339-48 Summary Summary 4 VITreducestheriskofasystemicallergic 4 . reduces t

he a reaction to 5% (wasp) to 15% (bees) 5 RiskofrelapsefromVITisincreasedin 5 . relapse subjects who have had: 1) a more severe allergicreaction

,2)honeybeeallergy,3) allergic reaction, allergy, systemic allergic reaction during VIT, and 4) y ears of treatment ; 6.Venom skin test or serum sIgEis unhel