Sting hymenoptera

J. O. Schmidt, M. S. Blum, and W. L. Overal. Comparative enzymology of venoms from stinging Hymenoptera. Toxicon 24 907 (1986). 

Schmidt, J.O., Blum, M.H , and Overal, W.L., 1980, Comparative lethality of venoms from stinging hymenoptera. Toxicon 18 469-474. 

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. 

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]. 

Bonadonna P, Perbellini O, Passalacqua G, et al Clonal mast cell disorders in patients with systemic reactions to Hymenoptera stings and increased serum tryptase levels. J Allergy Clin Immunol 2009 123 680-686. 

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. 

Venoms causing anaphylaxis or other allergic reactions originate almost exclusively from social Hymenoptera, most often honeybees and vespids (fig. 1) [1], occasionally from bumble bees [2], in America [3] and in Australia [4], also from ants. Stings by other insects like mosquitoes, bedbugs, fleas, horse flies and midges can very rarely also cause systemic allergic reactions. These are however not due to venoms but to... 

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

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. 

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... 

The indication for venom immunotherapy is based on a history of systemic allergic reactions to Hymenoptera stings and positive diagnostic tests, skin tests and/or venom-specific serum IgE antibodies [45, 49]. In the presence of only mild systemic allergic reactions, limited to the skin, immunotherapy is not generally recommended in the USA not for children, in Europe not for children and adults, unless they are heavily exposed and had repeated such reactions. 

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

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... 

Allergic reactions (eg, bronchospasm, urticaria, pruritus, angioneurotic edema, or swelling of the lips, eyelids, tongue, and nasal mucosa) due to anaphylactic shock caused by stinging insects (primarily of the order Hymenoptera, that includes bees, wasps, hornets, yellow jackets, bumble... 

Although relatively few insect species produce enough toxin to endanger humans, insects cause more fatal poisonings in the U.S. each year than do all other venomous animals combined. Most venomous insects are from the order Hymenoptera, which includes ants, bees, hornets, wasps, and yellow jackets. These insects deliver their toxins by a stinging mechanism. 

Hymenoptera envenomation results from the subcutaneous injection of venom through a stinging apparatus. 

Techniques for the diagnosis of anaphylactic sensitivity to hymenoptera (bees, wasps, ants, etc.) stings have been difficult to establish. Studies with commercially available whole body extracts of hymenoptera for skin testing were unable to discriminate between hypersensitive and control subjects. Use of hymenoptera venom skin tests clearly distinguishes between allergic and normal subjects and this venom was made available to the National Institute of Allergy and Infectious Diseases for further uses as a diagnostic material in 1976. ... 

Pickett, J.A., Williams, I.H. and Martin, A.P. (1982). (Z)-ll-Eicosen-l-ol, an important new pheromonal component from the sting of the honey bee. Apis melUfera L. (Hymenoptera, Apidae). J. Chem. Ecol. 8,163-175. 

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