Stinging insects

Insect venoms, together with foods and drugs, are the most frequent elicitors of anaphylaxis in men. The insect venom is applied by stings which must have occurred for more than 100,000 years, since human beings exist. Conflicts between stinging insects and humans occur while fighting for food, like honey or foods consumed outdoors, or while venomous insects feel threatened by human beings, most often near their nests. 

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. 

Schwartz HJ, Squillace DL, Sher TH, Teigland JD, Yunginger JW Studies in stinging insect hypersensitivity postmortem demonstration of antivenom IgE antibody in possible sting-related sudden death. Am J Clin Pathol 1986 85 607-610. 

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... 

FIGURE 9.2 Phylogenetic relationship between three different classes within the phylum arthropoda. The species shown in the different groups have all been implicated in allergic reactions (stinging insects excluded). 

Because of recent events, the awareness of responders to biological hazards associated with weapons of mass destruction has increased. These biological agents are certainly a matter of concern, but other biological hazards exist that responders are more likely to encounter. These include poison plants, biting and stinging insects, reptiles, and infections of cuts and scrapes. Responders who... 

Avoid stinging insects, and learn how not to attract them ... 

No, many insects and plants use serotonin as well. For example, serotonin is the trigger for swarm behavior in locusts. Many stinging insects, such as wasps and scorpions, have serotonin as part of their venom which they inject into their prey. The sudden large increase in serotonin levels in the region of injection site is interpreted by the prey s body as an indicator of bleeding, and the body experiences these signals as pain. 

Other food lures which have had practical use ia trapping insect pests include isoamyl saUcylate [87-20-7] for moths of the tomato and tobacco homworms, Manduca spp. heptyl butyrate [5870-93-0] for stinging yeUowjackets, Vespula spp. and l-octene-3-ol [3391-86-4] for the bloodsucking tsetse dies, Glossina spp. 

Bites and stings from spiders, insects, snakes, and other wildlife... 

Infections from contact with or exposure to bloodborne pathogens or other biological agents in contaminated soil, waste, dust, bird and animal droppings or transmitted by insect bites or 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]. 

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]. 

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]. 

Kipp YC, Struyvenberg A, van der Zwan JK Insect- 8 sting challenge in 138 patients relation between clinical severity of anaphylaxis and mast cell activation. J Allergy Clin Immunol 1992 90 110-118. 

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. 

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