Insect stings

Anaphylaxis most commonly starts with symptoms on the skin or the respiratory tract (table 2). The symptomatology is variable there is no obligatory involvement of all organ systems. A major characteristic of anaphylaxis is the rather rapid onset of symptoms after contact with the elicitor. The interval varies between a few seconds or minutes until 1 or 2 h, partly dependent upon the route of application (rapid onset after intravenous allergen exposure) and degree of sensitization. Experience in insect sting anaphylaxis in... 

Risk factors for insect sting-induced anaphylaxis ... 

Finally, patients suffering from mastocytosis have a higher risk of developing severe anaphylaxis after an insect sting [34]. In venom-allergic patients with mastocytosis, elevated baseline serum tryptase levels were foimd to be associated with severe anaphylactic reactions to stings [35]. 

Systemic anaphylaxis in man is frequently accompanied by electrocardiographic alterations ischemic ST waves, arrhythmias and atrial fibrillation [6-11]. Anaphylactic reactions after insect stings can lead to coronary spasm or acute myocardial infarction [12, 13]. Myocardial infarction can also occur as a consequence of idiopathic... 

Fontana L Paroxysmal atrial fibrillation after insect sting. J Allergy Clin Immunol 1996 98 759. 24... 

The most frequent symptoms of anaphylaxis in patients with mastocytosis are decreased blood pressure and tachycardia. Also observed are dizziness, dyspnea, flushing, nausea and diarrhea [4]. Severe reactions are typical for patients with mastocytosis. In 55 patients with insect sting allergy and confirmed mastocytosis, 81% of patients experienced severe anaphylaxis with shock or cardiopulmonary arrest, whereas clinical reactions of this severity occurred in only 17% of 504 patients without evidence for mastocytosis and normal tryptase levels [29]. In another study in... 

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]. 

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]. 

We will concentrate in this chapter on venoms of social Hymenoptera which are certainly responsible for more than 99% of insect sting-induced anaphylaxis. 

Miiller U Insect Sting Allergy Clinical Picture, 9 Diagnosis and Treatment. Stuttgart, Fischer/New... 

Reisman RE Natural history of insect sting allergy relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactions. J Allergy Clin InununoJ 1992 90 335-339. 

BJaauw PJ, Smithuis LOM The evaluation of the common diagnostic methods of hypersensitivity for bee and yellow jacket venom by means of an in-hospital insect sting. J Allergy Chn Immunol 1985 75 556-562. 

Van der Linden PW, Hack CE, Struyvenberg A, van der Zwan JK Insect sting challenge in 324 subjects with a previous anaphylactic reaction current criteria for insect venom hypersensitivity do not predict the occurrence and severity of anaphylaxis. J Allergy Clin Immunol 1994 94 1512-1519. 

Brown SG, Blackman KE, Stenlake V, Heddle RJ Insect sting anaphylaxis prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004 21 149-154. Lieberman P Use of epinephrine in the treatment of anaphylaxis. Curr Opin Allergy Clin Immunol 2003 3 313-318. 

Insect sting anaphylaxis prospective evaluation of treatment with intravenous adrenaline and volume 36 resuscitation. Emerg Med J 2004 21 149-154. 

Clark S, Long AA, Gaeta TJ, Camargo CA Jr Mulficenter study of emergency department visits for insect sting allergies. J Allergy Clin Immunol 2005 116 643-649. 

Histamine is a powerful stimulant of nerve endings, both motor and sensory nerves (32). Its stimulation is important in producing pain and itching, which are important components of the urticarial response and reactions to insect stings ( ). This effect is mediated through Hj receptors. Such nerve stimulation might conceivably be important in the initiation of the emetic response. 

The vasodilatory effect of Hi-receptor stimulation is mainly due to an endothelial release of nitric oxide, which is able to activate the soluble guany-late cyclase in vascular smooth muscle cells. This effect is mainly responsible for the erythema seen after injection (insect sting) of histamine. Furthermore, it is responsible, together with the increased capillary permeability, for the cardiovascular symptoms seen in anaphylactic or allergic shock. 

Chiu AM, Kelly KJ Anaphylaxis Drug allergy, insect stings, and latex. Immunol Allergy Clin North Am 2005 25 389. [PMID 15878462]... 

One in 10 persons, 22 million people, in the United States have allergies. Ten million of these suffer from the nasal discomfort of "hay fever" and six million from die more serious asthma. Substantial numbers of people in the United States die of allergic reactions to insect stings (more than 30 per year) or to injections of penicillin (300 per year in 1970). Foods, drugs, pollens, mold spores, mites in house dust, and even heat or cold can evoke serious allergic reactions. Among these eczema (atopic dermatitis) is very common. A major cause of allergic reactions has been... 

The toxicities of insect venoms are low to most people. Despite this, relatively large numbers of fatalities occur each year from insect stings because of allergic reactions in sensitized individuals. These reactions can lead to potentially fatal anaphylactic shock, which affects the nervous system, cardiovascular function, and respiratory function. The agents in bee venom that are responsible for severe allergic reactions are mellitin and two enzymes of high molecular mass — hyaluronidase and phospholipase A-2. 

To which order do most venomous insects belong What is the greatest danger from insect stings ... 

Location Histamine occurs in practically all tissues, but it is unevenly distributed, with high amounts found in lung, skin, and the gastrointestinal tract (sites where the inside of the body meets the outside ). It is found in high concentration in mast cells or basophils. Histamine also occurs as a component of venoms and in secretions from insect stings. 

An estimated 1-17% of the population of the United States is considered at risk for having an anaphylactic reaction if exposed to one or more allergens, especially penicillin and insect stings. Most affected individuals successfully avoid such allergens and will never experience anaphylaxis. Of those who actually experience anaphylaxis, up to 1% may die as a result. Anaphylaxis results in approximately 18 deaths per year in the USA (compared to 2.4 million deaths from all other causes each year). The most common presentation includes sudden cardiovascular collapse (88% of reported cases of severe anaphylaxis). 

Weather conditions are a major factor in the types of illnesses and injuries that the nurse will need to respond to. Papal visits to San Antonio and Denver resulted in many persons with heat-related illnesses (Gordon, 1988 Paul, 1993). Rapid changes in weather patterns during a mass event are associated with an increased number of individuals seeking care (Walsh, 1994). Insect stings occur primarily in warm weather. Warm weather events increase the likelihood of heat-related problems. 

Reisman R E 1994 Insect stings. New England Journal of Medicine 331 523-527 Shannon M 2000 Ingestion of toxic substances by children. New England Journal of Medicine 342 186-191... 

Bernard AA, Kersley JB. Sensitivity to insect stings in patients taking anti-inflammatory drugs. BMJ (Clin Res Ed) 1986 292(6517) 378-9. 

Although inflammation is essentially a normal defensive mechanism (a reaction to tissue injury, infection, inhalation of foreign proteins), the manifestations may be so serious and inappropriate or Involve such discomfort, that treatment with antiinflammatory agents is required. Inflammatory conditions can be acute (as in insect stings) or chronic (chronic asthma, dermatitis and other skin conditions, rheumatoid conditions). A wide range of drugs may be used to treat one or other inflammatory condition, and potential toxicity in relation to the medical condition is an important determinant of choice. 

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