Hymenoptera venoms

Berger J, Ring J Efficacy of antihistamine pretreat- 15 ment in the prevention of adverse reactions to Hymenoptera venom immunotherapy a prospective randomized placebo-controlled trial. J Allergy 16 Clin Immunol 1997 100 458-463. 

Hermann K, Ring J The renin-angiotensin system in patients with repeated anaphylactic reactions during Hymenoptera venom hyposensitization and sting challenge. Int Arch Allergy Immunol 1997 11 251-256. 

Bonifazi F, Jutel M, Bilo BM. Bimbaum J. Muller U EAACI Interest Group on Insect Venom Hypersensitivity Prevention and treatment of Hymenoptera venom allergy guidelines for chnical practice. Allergy 2005 60 1459-1470. 

Rueff F, Placzek M, Przybilla B Mastocytosis and 44 Hymenoptera venom allergy. Curr Opin Allergy Clin Immunol 2006 6 284-288. 

Sturm GJ, Heinemann A, Schuster C, et al Influence 46 of total IgE levels on the severity of sting reactions in Hymenoptera venom allergy. Allergy 2007 62 884-889. 

Hymenoptera venom is a prominent trigger of systemic reactions. Severe and fatal reactions have been described in patients with mastocytosis [9, 30, 31]. In few cases with urticaria pigmentosa and Hymenoptera venom anaphylaxis, no sensitization could be detected by means of skin tests and determination of specific IgE antibodies [32]. However, larger series found evidence that these systemic reactions are normally IgE-mediated insect sting allergies [7,33]. 

Diet should be modified only in cases where foods have been proven to elicit symptoms. Patients with mastocytosis and Hymenoptera venom exposure are at risk for severe anaphylaxis. Thus, specific immunotherapy should be considered in patients with Hymenoptera venom allergy and then administered under close supervision [31]. The majority of patients with mastocytosis reportedly tolerate immunotherapy without significant side effects and appear protected following this approach [33,40]. However, there does appear to be some increased risk for adverse reactions during initiation of immunotherapy, as well as for therapy failures [31, 33]. An increased maintenance dose of insect venom has been reported to carry better success rates by sting provocation [41]. Also, in the light of 2 fatal cases of anaphylaxis after discontinuation of SIT in patients with mastocytosis [30], lifelong immunotherapy should be considered [26]. 

Gonzalez de Olano D, Alvarez-Xwose I, Esteban-Lopez MI, et al Safety and effectiveness of immunotherapy in patients with indolent systemic mastocytosis present- 44 ing with Hymenoptera venom anaphylaxis. J Allergy Clin Immunol 2008 121 519-526. 

Rueff F, Wenderoth 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 1027-1032. 

One limitation of serum-specific IgE is that given the cross-reactivity between different Hymenoptera venoms, and also due to the presence of anti-carbohydrate antibodies, it is frequent to find several simultaneous positive results in patients with non-identified insect stings, a situation which makes diagnosis of the same difficult. In these cases, RAST inhibition and the release of histamine occasionally provide data on the venom involved and when this is not the case, it is advisable to administer immunotherapy against both [44]. 

Ebo D, Hagendorens MM, Bridts CH, De Clerk LS, Stevens WJ Hymenoptera venom allergy taking the sting out of difficult cases. J Investig Allergol Clin Immunol 2007 17 357-360. 

Hymenoptera venoms are composed of biogenic amines and other low molecular weight substances, of basic peptides and of proteins. Injection of venom by Hymenoptera stings has toxic effects, due to biogenic amines, peptides and proteins biogenic amines such as histamine cause pain, are vasodilatory and increase... 

Fatal reactions to Hymenoptera stings are rare they range from 0.09 to 0.48 per million inhabitants and year [31, 32]. However, the true number may be underestimated in one study, specific IgE antibodies to Hymenoptera venoms were detected in 23% of postmortem serum samples from patients who died outdoors from unknown reasons [33]. Between 1961 and 2004, 140 fatal Hymenoptera sting reactions were registered by the federal administration for statistics in Switzerland with about 7.5 million inhabitants, resulting in an average annual fatality rate of 3.18. If these data are extrapolated to Europe with a population of around 500 million, the annual death rate in Europe would amount to about 200. 

The natural history of Hymenoptera venom anaphylaxis, that is the risk to develop anaphylaxis again when re-stung, has been analyzed in several prospective studies (table 3) [35-37], and in placebo or whole-body extract treated controls of prospective studies on venom immunotherapy [38-40]. It is higher in patients with a history of severe as compared to mild systemic anaphylactic reactions, and in honey bee than in vespid venom-allergic patients - most likely because of the smaller and less constant amoimt of venom applied by vespids [10,41]. A short interval between two stings increases the risk of anaphylaxis [25], but severe anaphylaxis may occur again even after intervals of 10-20 years or more. 

After a painful sting the elicitor of Hymenoptera venom-induced anaphylaxis is usually clear. However the identification of the responsible species is often difficult. 

Table 3. Natural history of Hymenoptera venom allergy... 

While in anaphylaxis caused by other frequent elicitors like food and drugs, allergen-specific immunotherapy is not established, immimotherapy with Hymenoptera venoms has been shown to be effective in three prospective controlled trials (table 4) [38-40] and also in a number of studies where patients were submitted to a sting challenge with the responsible insect during venom immimotherapy (table 5) [44]. While over 90% of vespid venom-allergic patients are fully protected and do not develop any... 

Hoffman DR Hymenoptera venoms composition, standardization, stabihty in Levine MI, Lockey RF (eds) Monograph on Insect Allergy. Pittsburgh, Lambert Assoc, 2003, pp 37-53. 

Hoffman DR, Jacobsen RS Allergens in Hymenoptera venoms. XII. How much protein is in a sting Ann Allergy 1984 52 276-278. 

MW, Grunwald T, Spillner E Identification, recom- 28 binant expression and characterization of the 100 kDa high molecular weight hymenoptera venom allergens Api m5 and Ves v3. Allergy 2008 63(Suppl 88) 13-14. 29... 

Nielsen J. Haeberli G Hymenoptera venom allergy analysis of double positivity to honey bee and Vespula venom by estimation of IgE antibodies to 38 species-specific major allergens Api ml and Ves v5. Allergy 2009 64 543-548. 

Elberink JNG, Birnbaum J. et al Diagnosis of sO Hymenoptera venom allergy. EA ACI position paper. AUergy 2005 60 1339-1349. 

Settipane GA, Newstead GJ, Boyd GK Frequency of Hymenoptera venom allergy in an atopic and normal population. J Allergy Clin Immunol 1972 50 146-150. Nall TM Analysis of 677 death certificates and 168 autopsies of stinging insects deaths. J Allergy Clin Immunol 1985 75 207. 

Rueff F, Przybilla B, Muller U, Mosbech H Position paper The sting challenge test in Hymenoptera venom allergy. Allergy 1996 51 216-225. 51... 

Muller UR, Golden DBK, Lockey RF, Shin B Immunotherapy for Hymenoptera venom hypersensitivity in Lockey RF, Ledford DK (eds) Allergens and Allergen Immunotherapy. New York, Informa Healthcare, 2008, pp 377-392. 

Muller U, Haeberli G Use of (J-blockers during immunotherapy for Hymenoptera venom allergy. J Allergy Clin Immunol 2005 60 115 606-610. 

Muller UR, Mosbech H Position paper Immunotherapy with hymenoptera venoms. Allergy 1993 48 36-46. 

Aalberse, R.C., Koshte, V., and Clemens, J.G. 1981. Immunoglobulin E antibodies that cross-react with vegetable foods, pollen, and Hymenoptera venom. J Allergy Clin Immunol 68 356-364. 

Wolf BL, Hamilton RG. Near-fatal anaphylaxis after Hymenoptera venom immunotherapy J Allergy Clin Immunol 1998 102(3) 527-8. 

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