Insect sting allergy Presented by Chuleeporn Kongmeesook, MD, 2013

1. INSECT ALLERGY
CHULEEPORN KONGMEESOOK ,MD

2. Outline
Epidemiology
Clinical presentations
Diagnosis
Treatment

3. Apidae
Vespidae
Formocidae
Pesek et al. Allergy Asthma Immunol Res. 2013 May;5(3):129-137.
May;5 ):129-137.
Bilό et al. Allergy 2005;60: 1339–1349.
Bilό
2005;60: 1339–1349.

4. Apidae

5. Vespidae

6. Formicidae

7. Pesek et al. Allergy Asthma Immunol Res. 2013 May;5(3):129-137.
May;5 ):129-137.
Bilό et al. Allergy 2005; 60: 1339–1349.
Bilό
2005; 60: 1339–1349.

8. Cross reactivity 1
Double or even multiple positive tests
can be caused by true double
sensitization or by cross-reactive
crossIgE antibodies.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

9. Cross reactivity 2
Within Apidae family
Venoms and major allergens of different
honeybees worldwide very similar
(Phospholipase A2).
Bumblebee PLA2 is only 53%.
PLA2
53%.
Immunologic cross-reactivity exist between
crosshoneybee and bumblebee venoms
venoms.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

10. Cross reactivity 3
Within vespid venoms
CrossCross-reactivity among vespids is strong,
due to similarities of venom composition
and structure of single allergens.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

11. Cross reactivity 4
Between venoms of Apidae and Vespidae
Hyaluronidase (major crossreactive
component) 50% sequence identity between
component) 50%
honeybee and vespid venoms
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

12. Epidemiology 1
Depending on country’s climate.
56.
56.6 – 94.5% stung by Hymenoptera insect
94.
at least once in live.
Prevalence 9.3 - 28.7% in adult.
28.
Bilό et al. Allergy and Clinical Immunology 2008 ; 8:330–337
Bilό
330–

13. Epidemiology 2
Systemic allergic reactions up to 3% of
adults and 1% of children.
Large local reactions uncertain, estimated
10%
10% in adults.
Fatal stings at least 40 each year in USA and
16–
16–38 in France.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

14. Epidemiology in Thailand 1
Chulalongkorn
Etiologies of anaphylaxis : Drug 48 %,
Food 31 %, Contrast media 6 %, Unknown
5 % and Insect sting 4 %.
Techapornroong M et al Asian Pac J Allergy Immunol 2010;28:262-9.
2010;28:262-

15. Epidemiology in Thailand 2
Siriraj
Causes of Anaphylaxis : Drugs 50 %,
Foods 24 %, Idiopathic 15 % and Insect
stings/bites 11 %.
Jirapongsananuruk O et al Ann Allergy Asthma Immunol. 2007;98:157–162.
2007;98:157–162.

16. Epidemiology in Thailand 3
Thammasat
Causes of Anaphylaxis : Foods 40 %,
Drugs 36 %, Unidentified 17 % and
Hymenoptera 5 %.
Poachanukoon O et al ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY 2006; 24:111-116 .
2006; 24:111-

17. เดลิ นิวส์ 24 เมษายน 2556

18. Clinical presentations
Local reaction
Large local reaction
Systemic reaction
Unusual reaction
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

19. Risk factors of Hymenoptera venom allergy
Time interval between stings, number of
stings
Venom sensitization
Severity of preceding reaction
Age
Cardiovascular diseases, b-blockers
bInsect
Elevated serum tryptase, mastocytosis
tryptase,
M. T. Krishna et al Clinical & Experimental Allergy 2011 ;41:1201–1220.
41:1201–1220.
Bilό et al. Clinical & Experimental Allergy 2009 ;39: 1467–1476
Bilό
39: 1467–
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

20. Diagnosis
Clinical history
Skin tests
In vitro tests
Sting challenge test
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

21. Treatment of acute reactions
www.eaaci.net

22. Preventing insect stings
www.cdc.gov

23. Preventing fire ant stings and bites
www.cdc.gov

24. Venom immunotherapy 1
Indication
History of previous systemic reaction to a
sting and evidence of venom-specific IgE
venomantibodies.
Goal
Prevent systemic reactions.
Alleviate patients’ anxiety related to
insect stings.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

25. www.eaaci.net

26. Bovie RJ et al. The Cochrane Collaboration 2012 ;1-70.
70.

27. Valentine et al. N Engl J Med 1990;323:1601-3.
1990;323:1601-

28. David B.K. Golden et al N Engl J Med 2004;351:668-74.
2004;351:668-74.

29. Venom immunotherapy 2
Selection of venom in honey bee and
bumblebee
Marked cross-reactivity.
crossHoneybee venom alone will be sufficient.
Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

30. Venom immunotherapy 3
Selection of venom in vespids
CrossCross-reactivity exists between major
venom components of several vespids.
vespids.
Most common therapy for vespid
sensitivity is mixed vespid venoms.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

31. Venom immunotherapy 4
Selection of venom in Apidae and Vespidae
CrossCross-reactivity very limited
limited.
Treatment with both venoms only indicated in
double sensitization.
Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

32. Venom immunotherapy 5
Duration of venom immunotherapy
Should continued at least 3 - 5 years.
Some patients need to continue for
extended period of time or indefinitely.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

33. GOLDEN ET AL J Allergy Clin Immunol 2000;105:385-90
2000;105:385-

34. Venom immunotherapy 6
Efficacy
95–100%
95–100% effective in preventing systemic
reactions to stings.
100 µg dose of individual venoms
(honeybee, yellow jacket or Polistes wasp)
have 75–95% efficacy.
75–95% efficacy.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

35. Venom immunotherapy 7
Safety
Systemic symptoms occur in 5–15% during
15%
initial weeks of treatment.
Pretreatment with antihistamines reduce
local and systemic reactions, and may
reduce frequency of systemic reactions.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

36. Venom immunotherapy 8
Treatment protocol
Traditional regimen
Modified rush
Rush regimen
UltraUltra-rush regiment
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

38. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

39. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

40. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

41. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

43. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

44. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

45. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

46. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

47. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

48. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

49. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

50. Take Home Message
Systemic reaction from insect sting
and venom-specific IgE antibodies should
venomreceive VIT.
VIT should continue for at least 3-5 yrs.

51. THANK YOU