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hymenoptera (insect) sting

Pathology: - IgE cross-reactive with venoms of yellow jackets, wasps & hornets but not cross-reactive with venom of bees - systemic reaction (anaphylaxis, angioedema) in < 7% of people who are stung - 25% of people have large local reaction [3] Clinical manifestations: 1) normal reaction following any sting or bite a) immediate local pain with swelling b) subsides within 1-2 hours c) pruritus that may persist for days 2) large local reaction a) swelling extending from sting site over large area b) peaks at 48 hours, may persist up to 1 week 3) manifestations of corneal bee sting - may range from mild irritation to loss of vision (case report) [6] - corneal haziness due to corneal edema - stinger may remain embedded in cornea Laboratory: 1) venom-specific IgE 2) leukocytosis & hyperglycemia typical of stress reaction 3) baseline serum tryptase can identify patients at high risk for anaphylaxis & those with mastocytosis [4] 4) allergen skin testing* - indicated only for systemic reaction (anaphylaxis, angioedema) - not indicated after large local reaction [3] - specific IgE antibodies to Hymenoptera venom in 40% of the general population [3] - delay for one month after sting * Hymenoptera venom skin testing Complications: - anaphylaxis - corneal bee stings may result in corneal injury & secondary glaucoma (case report) [6] Management: 1) local reaction a) cool compresses b) topical lotions - calamine - camphor-menthol c) secondary infection treated as cellulitis with antibiotics d) antihistamines - chlorpheniramine 4-8 mg every 6 hours - diphenhydramine 50 mg PO every 6 hours e) prednisone 40 mg PO for 2-3 days 2) corneal bee sting - moxifloxacin ophthalmic with stinger removed under local anesthesia (case report) [6] - cleanse anterior chamber,suture as needed - 2-week course of topical glucocorticoid, antibiotic, & cycloplegic 3) treat anaphylaxis 4) patients with history of systemic reaction should carry insect sting kit 5) venom immunotherapy [2] a) small risk of inducing anaphylaxis with immunotherapy b) patients must still carry insect sting kit c) indications - history of anaphylaxis to hymenoptera sting + positive skin testing to hymenoptera venom [3] - patient anxiety disrupts activities of daily living - occupational risk - house painter - outdoor construction worker - forestry workers d) 5 years of venom immunotherapy [4] e) sting challenges most reliable way to determine effectiveness of venom immunotherapy [5]

Related

allergen skin testing anaphylaxis insect bite insect sting or anaphylaxis kit (Ana-Kit)

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sting

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1172-74
  2. Journal Watch 24(19):154-55, 2004 Golden DB, Kagey-Sobotka A, Norman PS, Hamilton RG, Lichtenstein LM. Outcomes of allergy to insect stings in children, with and without venom immunotherapy. N Engl J Med. 2004 Aug 12;351(7):668-74. PMID: 15306668 - Gruchalla RS. Immunotherapy in allergy to insect stings in children. N Engl J Med. 2004 Aug 12;351(7):707-9. No abstract available. PMID: 15306673
  3. Amrol DJ NEJM Journal Watch. July 3, 2014 Massachusetts Medical Society (subscription needed) http://www.jwatch.org Sturm GJ et al. Sensitization to Hymenoptera venoms is common, but systemic sting reactions are rare. J Allergy Clin Immunol 2014 Jun; 133:1635 PMID: 24365141 http://www.jacionline.org/article/S0091-6749%2813%2901707-7/abstract
  4. Golden DB, Demain J, Freeman T et al. Stinging insect hypersensitivity: A practice parameter update 2016. Ann Allergy Asthma Immunol 2017 Jan; 118:28. PMID: 28007086 http://www.annallergy.org/article/S1081-1206(16)31270-4/abstract
  5. Anello J, Feinberg B, Heinegg J et al Hymenoptera Venom Allergy Guidelines on hymenoptera venom allergy immunotherapy by the European Academy of Allergy and Clinical Immunology. Medscape: New Guidelines and Recommendations, August 2017. http://reference.medscape.com/viewarticle/884517
  6. Mendonca TM, Rodrigues GR Images in Clinical Medicine: Corneal Bee String. N Eng J Med. 2020. Nov 28 PMID: 33252203 https://www.nejm.org/doi/full/10.1056/NEJMicm2024132