insect sting allergy

INSECT ALLERGYINSECT ALLERGYINSECT ALLERGYINSECT ALLERGYINSECT ALLERGYINSECT ALLERGYINSECT ALLERGYINSECT ALLERGYCHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD

Outline Outline

�� EpidemiologyEpidemiology

�� Clinical presentationsClinical presentations�� Clinical presentationsClinical presentations

�� DiagnosisDiagnosis

�� TreatmentTreatment

Apidae Vespidae Formocidae

PesekPesek et al. Allergy Asthma et al. Allergy Asthma ImmunolImmunol Res. Res. 2013 2013 May;May;55((33):):129129--137137. .

BilBilόό et al. Allergy et al. Allergy 20052005;;6060: : 13391339––13491349..

ApidaeApidae

VespidaeVespidae

FormicidaeFormicidae

PesekPesek et al. Allergy Asthma et al. Allergy Asthma ImmunolImmunol Res. Res. 2013 2013 May;May;55((33):):129129--137137. .

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349..

Cross reactivity Cross reactivity 11

�� Double or even multiple positive tests Double or even multiple positive tests

can be caused by true double can be caused by true double

sensitization or by crosssensitization or by cross--reactive reactive

IgEIgE antibodies.antibodies.

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349

Cross reactivity Cross reactivity 22

Within Within ApidaeApidae family family

�� Venoms and major allergens of differentVenoms and major allergens of different

honeybees worldwide very similarhoneybees worldwide very similar honeybees worldwide very similarhoneybees worldwide very similar

((PhospholipasePhospholipase AA22))..

�� Bumblebee PLABumblebee PLA2 2 is only is only 5353%.%.

�� Immunologic crossImmunologic cross--reactivity exist between reactivity exist between

honeybee and bumblebee venomshoneybee and bumblebee venoms.

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349

Cross reactivity Cross reactivity 33

Within Within vespidvespid venomsvenoms

�� CrossCross--reactivity among reactivity among vespidsvespids is strong, is strong,

due to similarities of venom composition due to similarities of venom composition

and structure of single allergens.and structure of single allergens.

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349

Cross reactivity Cross reactivity 44

Between venoms of Between venoms of ApidaeApidae and and VespidaeVespidae

�� HyaluronidaseHyaluronidase ((major major crossreactivecrossreactive

componentcomponent) ) 5050% sequence identity between % sequence identity between

honeybee and honeybee and vespidvespid venomsvenoms

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349

Epidemiology Epidemiology 11

�� Depending on country’s climate. Depending on country’s climate.

�� 5656..6 6 –– 9494..55% stung by Hymenoptera insect % stung by Hymenoptera insect

at least once in live.at least once in live.

�� Prevalence Prevalence 99..3 3 -- 2828..77% in adult.% in adult.

BilBilόό et al.et al. Allergy and Clinical Immunology Allergy and Clinical Immunology 2008 2008 ; ; 88::330330––337337

Epidemiology Epidemiology 22

�� Systemic allergic reactions up to Systemic allergic reactions up to 33% of % of

adults and adults and 11% of children. % of children.

�� Large local reactions uncertain, estimated Large local reactions uncertain, estimated

1010% in adults. % in adults.

�� Fatal stings at least Fatal stings at least 40 40 each year in USA and each year in USA and

1616––38 38 in France.in France.

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

Epidemiology in Thailand Epidemiology in Thailand 11

�� ChulalongkornChulalongkorn

Etiologies of anaphylaxis : Drug Etiologies of anaphylaxis : Drug 48 48 %, %,

Food Food 31 31 %, Contrast media %, Contrast media 6 6 %, Unknown %, Unknown

5 5 % and Insect sting % and Insect sting 4 4 %.%.

TechapornroongTechapornroong M et al Asian Pac J Allergy M et al Asian Pac J Allergy ImmunolImmunol 20102010;;2828::262262--99..

Epidemiology in Thailand Epidemiology in Thailand 22

�� SirirajSiriraj

Causes of Anaphylaxis : Drugs Causes of Anaphylaxis : Drugs 50 50 %, %,

Foods Foods 24 24 %, Idiopathic %, Idiopathic 15 15 % and Insect % and Insect

stings/bites stings/bites 11 11 %.%.

JirapongsananurukJirapongsananuruk O et al O et al Ann Allergy Asthma Immunol. Ann Allergy Asthma Immunol. 20072007;;9898::157157––162162..

Epidemiology in Thailand Epidemiology in Thailand 33

�� ThammasatThammasat

Causes of Anaphylaxis : Foods Causes of Anaphylaxis : Foods 40 40 %, %,

Drugs Drugs 36 36 %, Unidentified %, Unidentified 17 17 % and % and

Hymenoptera Hymenoptera 5 5 %. %.

PoachanukoonPoachanukoon O et al ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY O et al ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY 20062006; ; 2424::111111--116 116 ..

เดลินิวส์เดลินิวส์ 24 24 เมษายนเมษายน 25562556

Clinical presentationsClinical presentations

�� Local reactionLocal reaction

�� Large local reactionLarge local reaction

�� Systemic reactionSystemic reaction

�� Unusual reactionUnusual reaction

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

�� Time interval between stings, number of Time interval between stings, number of stingsstings

�� Venom sensitizationVenom sensitization

�� Severity of preceding reactionSeverity of preceding reaction

Risk factors of Hymenoptera venom allergyRisk factors of Hymenoptera venom allergy

�� Severity of preceding reactionSeverity of preceding reaction

�� AgeAge

�� Cardiovascular diseases, bCardiovascular diseases, b--blockersblockers

�� InsectInsect

�� Elevated serum Elevated serum tryptasetryptase, , mastocytosismastocytosis

M. T. Krishna et al M. T. Krishna et al Clinical & Experimental Allergy Clinical & Experimental Allergy 2011 2011 ;;4141::12011201––12201220..

BilBilόό et al. Clinical & Experimental Allergy et al. Clinical & Experimental Allergy 2009 2009 ;;3939: : 14671467––14761476

BilBilόό et al. Allergy et al. Allergy 20052005; ; 6060: : 13391339––13491349

�� Clinical history Clinical history

�� Skin tests Skin tests

DiagnosisDiagnosis

�� In vitro tests In vitro tests

�� Sting challenge test Sting challenge test

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

Treatment of acute reactionsTreatment of acute reactions

www.eaaci.net www.eaaci.net

Preventing insect stingsPreventing insect stings

www.cdc.govwww.cdc.gov

Preventing fire ant stings and bitesPreventing fire ant stings and bites

www.cdc.govwww.cdc.gov

Venom immunotherapy Venom immunotherapy 11IndicationIndication

�� History of previous systemic reaction to a History of previous systemic reaction to a

sting and evidence of venomsting and evidence of venom--specific specific IgEIgE

antibodies.antibodies.antibodies.antibodies.

GoalGoal

�� Prevent systemic reactions.Prevent systemic reactions.

�� Alleviate patients’ anxiety related to Alleviate patients’ anxiety related to

insect stings.insect stings.

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

www.eaaci.net www.eaaci.net

BovieBovie RJ et al. The Cochrane CollaborationRJ et al. The Cochrane Collaboration 2012 2012 ;;11--7070..

Valentine et al. N Valentine et al. N EnglEngl J Med J Med 19901990;;323323::16011601--33..

David B.K. Golden et al N David B.K. Golden et al N EnglEngl J Med J Med 20042004;;351351::668668--7474..

Venom immunotherapy Venom immunotherapy 22

Selection of venom in honey bee and Selection of venom in honey bee and

bumblebee bumblebee

�� Marked crossMarked cross--reactivity.reactivity.

�� Honeybee venom alone will be sufficientHoneybee venom alone will be sufficient..

BonifaziBonifazi et al. Allergy et al. Allergy 20052005; ; 6060: : 14591459––14701470

Venom immunotherapy Venom immunotherapy 33

Selection of venom in Selection of venom in vespidsvespids

�� CrossCross--reactivity exists between major reactivity exists between major

venom components of several venom components of several vespidsvespids. . venom components of several venom components of several vespidsvespids. .

�� Most common therapy for Most common therapy for vespidvespid

sensitivity is mixed sensitivity is mixed vespidvespid venoms.venoms.

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717BonifaziBonifazi et al. Allergy et al. Allergy 20052005; ; 6060: : 14591459––14701470

Venom immunotherapy Venom immunotherapy 44

Selection of venom in Selection of venom in ApidaeApidae and and VespidaeVespidae

�� CrossCross--reactivity very limitedreactivity very limited.

�� Treatment with both venoms only indicated in Treatment with both venoms only indicated in

double sensitization.double sensitization.

BonifaziBonifazi et al. Allergy et al. Allergy 20052005; ; 6060: : 14591459––14701470

Venom immunotherapy Venom immunotherapy 55

Duration of venom immunotherapyDuration of venom immunotherapy

�� Should continued at least Should continued at least 3 3 -- 5 5 years.years.

�� Some patients need to continue for Some patients need to continue for

extended period of time or indefinitely.extended period of time or indefinitely.

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL GOLDEN ET AL J Allergy Clin Immunol J Allergy Clin Immunol 20002000;;105105::385385--9090

Venom immunotherapy Venom immunotherapy 66

EfficacyEfficacy

�� 9595––100100% effective in preventing systemic% effective in preventing systemic

reactions to stings.reactions to stings.

�� 100 100 µgµg dose of individual venoms dose of individual venoms

(honeybee, yellow jacket or (honeybee, yellow jacket or PolistesPolistes wasp)wasp)

have have 7575––9595% efficacy% efficacy..

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

Venom immunotherapy Venom immunotherapy 77

SafetySafety

�� Systemic symptoms occur in Systemic symptoms occur in 55––1515% during % during

initial weeks of treatment.initial weeks of treatment.

�� Pretreatment with antihistamines reduce Pretreatment with antihistamines reduce

local and systemic reactions, and may local and systemic reactions, and may

reduce frequency of systemic reactions.reduce frequency of systemic reactions.

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

Venom immunotherapy Venom immunotherapy 88

Treatment protocolTreatment protocol

�� Traditional regimenTraditional regimen

Modified rushModified rush�� Modified rushModified rush

�� Rush regimenRush regimen

�� UltraUltra--rush regimentrush regiment

Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 20092009. p. . p. 10051005--1717

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

S.C. Stokes et al. Ann Allergy Asthma S.C. Stokes et al. Ann Allergy Asthma ImmunolImmunol 20132013;;110 110 ::165165 --167167

S.C. Stokes et al. Ann Allergy Asthma S.C. Stokes et al. Ann Allergy Asthma ImmunolImmunol 20132013;;110 110 ::165165 --167167

S.C. Stokes et al. Ann Allergy Asthma S.C. Stokes et al. Ann Allergy Asthma ImmunolImmunol 20132013;;110 110 ::165165 --167167

S.C. Stokes et al. Ann Allergy Asthma S.C. Stokes et al. Ann Allergy Asthma ImmunolImmunol 20132013;;110 110 ::165165 --167167

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

GOLDEN ET AL J ALLERGY CLIN IMMUNOL GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 2011 ;;127127::852852--44

Take Home MessageTake Home Message

�� Systemic reaction from insect stingSystemic reaction from insect sting

and venomand venom--specific specific IgEIgE antibodies shouldantibodies should

receive VIT.receive VIT.receive VIT.receive VIT.

�� VIT should continue for at least VIT should continue for at least 33--5 5 yrs.yrs.

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