Dean Tey i All e r g i st Imm u n o l i st aedatcegstuoogst Monday 17 June 2010 InsectStingAllergy Insect 1E pgy 2Aetiology meet the insects3Clinical presentation 4Risk of future systemic r ID: 960547
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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 - In 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 abdomenIll temperedNests 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-blackYellow/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 involvedSingle (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 reactionsNumber of stings h e g
i espec a Oteaegesespecayasta Social historyRisk 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 yearThe 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