Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Stinging insect allergy changing concepts Wilma C. Light & Robert E. Reisman To cite this article: Wilma C. Light & Robert E. Reisman (1976) Stinging insect allergy changing concepts, Postgraduate Medicine, 59:4, 153-157, DOI: 10.1080/00325481.1976.11714333 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714333
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 12 August 2017, At: 09:34
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• Allergie reactions following the sting of the bee, yellow jacket, wasp, or bornet are prevalent each summer and fall and account for at least 40 deaths annually in the United States. 1 In ail probability, addition al deaths after insect stings are erroneously attributed to other causes. Recent advances in immunologie techniques have allowed new insight into the pathogenesis of the allergie response to insect stings. Such information may change traditional aspects of diagnosis and treatment. Types of Reactions
A mild local reaction consisting of pain, erythema, and swelling for several centimeters around the site of the sting is the normal response. Swelling subsides in several hours. A moderate to severe local reaction consists of a larger area of swelling than normal, whieh may persist for several days. The swelling may be extensive; for example, a sting on the band might result in swelling to the elbow. Systemie reactions are classieally anaphylactie, usually occur within minutes of the sting, and may be fatal. Symptoms may include angioedema, urticaria, laryngeal edema, bronchospasm, diarrhea, abdominal or uterine cramps, and shock. Taxie reactions are systemie, are induced by multiple stings, and are thought to be due to pharmacologie agents present in the venom. Unusual reactions, often involving the vascular or neurologie system, may follow insect stings (eg, acute glomerulonephritis, serum sickness, Guillain-Barré syndrome). The etiology of such reactions is not known. Certain individuals who essentially have been immunized with venom (eg, beekeepers) may experience no reaction at ali after a bee sting.
stinging insect allergy changing concepts Wilma C. Light, MD Robert E. Reisman, MD State University of New York at Buffalo
consider What immunologie events follow an insect sting? What are the most reliable diagnostic measures for determining whether a person is likely to experience an allergie reaction to an insect sting? How effective is immunotherapy using whole-body extract? Using venom?
Epidemiology
The incidence of acute generalized allergie reactions in the general population has been estimated to be 0.38% to 0.40%. Reactions occur most often in males under the age of 20 years. In our experience with over 400 patients, we have found a ratio of60% males to 40% females. Yellow jacket stings account for more reactions than the stings of other Hymenoptera. 2 - 6 Ali of the foregoing observations can probably be explained
Vol. 59 • No. 4 o April1976 o POSTGRADUATE MEDICINE
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on the basis of opportunity. Children and young people spend more time outdoors than do other age groups, and boys are stung more often than girls. The yellow jacket is fond of food and garbage found at picnics and campsites. Furthermore, its nest is often found in the ground, where it is easily disturbed inadvertently. Ali Hymenoptera will sting to proteot their nest. Most deaths from Hymenoptera stings occur in adults. 1•7 Stings of the head and neck area are more likely to result in systemic reactions than are stings of the extremities, although stings in any area of the body can result in anaphylaxis. About 80% offatalities occur with no apparent prior indication of insect hypersensitivity. ln severa! studies, a time relationship between stings bas not been found. However, we have noted many individuals who reported an uneventful sting two to four weeks prior to the sting that resulted in the systemic reaction. Figure 1. Relative amounts of specifie IgE antibodies to bee venom and whole-bee extract (WBE) in beekeepers, untreated patients, and nonallergic contrais. Relative amounts of IgE antibodies as determined on radioallergosorbent test (RAST) are expressed as a percent of a positive control. Levels greater than 10% are significant.
Figure 2. Distribution of specifie IgE antibodies to bee, yellow jacket, and hornet venom in the serum of 99 insect-allergic patients.
154
Dlagnosls
Because of the pain induced, there is usually little difficulty in relating a sting to a subsequent reaction. Only the bee leaves its stinger in place. Most individuals have difficulty in distinguishing one insect from another, even if they happen to see it. Over 30 years ago, Benson and SemenovB tested a beekeeper with venom and with a whole-body extract (WBE) prepared by grinding the who le insect. The patient reacted to both substances, leading Benson9 to conelude that there is a common allergen found in both venom and bee-body protein. This observation is the foundation for subsequent diagnosis and therapy with WBE. More recent! y, investigators 10•11 have questioned the value of WBE for diagnosis. Skin tests with WBE have failed to produce reactions in patients with very convincing histories of anaphylaxis and have produced reactions in many individuals not sensitive to stings. Experiments by Shulman and colleagues12 with rabbits immunized with venom and WBE suggested that venom contained two antigens, one unique to venom and a
POSTGRADUATE MEDICINE o April1976 o Vol. 59 o No. 4
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
weaker one present also in the WBE. Rabbits immunized with WBE produced an antibody specifie ta WBE which did not react with venom. Therefore, venom and WBE appear ta have separate major antigenic determinants. Hunt and colleagues 11 performed skin tests with venom and WBE on sensitive patients and contrais and compared the results with those of in vitro assessment of histamine release. Leukocytes from sensitive patients were incubated with antigen, and histamine release was measured. Very good correlation was found between the results of venom skin tests and venom-induced histamine release. However, the WBE skin tests failed ta distinguish sensitive patients from contrais. In our laboratory, we compared results of bee-venom skin tests with results of the radioallergosorbent test (RAST), which detects circulating specifie IgE antibodies. Serum from sensitive patients is incubated with antigen attached chemically ta inert cellulose disks. The disks are labeled with radioactive anti-IgE and, after washing, are counted in a gamma counter. The count per minute is proportion al ta the leve! of circulating specifie IgE antibody. We have found very good correlation between results of bee-venom skin tests and bee-venom-specific IgE antibody levels. WBE skin tests were a poor discriminator of patients with positive bee-venom skin tests or elevated circulating venom-specific IgE antibodies. Only half of the patients with bee-venam-specifie IgE had positive WBE skin tests or elevated WBE IgE antibodies. In addition, 10% of nonsensitive patients had false-positive WBE skin tests. These observations confirm the poor reliability of WBE skin tests. Although bee venom has been licensed for testing, it is not commercially available at present. In vitro tests (histamine release and RAST) are excellent substitutes, although they are available at present only in severa! research laboratories. The relative amounts of IgE antibodies ta bee venom and WBE in a group of beekeepers, untreated patients, and nonallergic contrais are compared in figure 1.
Vol. 59 • No. 4 • April 1976 • POSTGRADUATE MEDICINE
Figure 3. Comparison of total antibodies to bee venom in the serum of beekeepers, allergie patients before and after treatment with WBE, and nonallergic contrais. Only 12 of 47 contrais with total antibodies less than 2~o~-g/ml are indicated on chart.
Immunologie Events Followlng a Stlng
Measurable levels of IgE antibody ta venom are not normally found in the serum of nonallergic contrais or in individuals who have been stung without a reaction. IgE antibodies reacting with bee, yellow jacket, or bornet venoms were measured in a large group of insect-sensitive patients. Elevated levels of IgE antibodies ta one or more venoms were found in the vast majority of these patients. Figure 2 shows the distribution of antibodies in 99 insect-sensitive patients. Whether multiple-insect sensitivity results from separate stinging incidents or, more likely, from sorne cross-reactivity between venoms can only be a matter of speculation at present. When sequential serum specimens were available shortly after the time of sting, we
155
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
Until immunologically active material becomes available for the immunotherapy of insect stings, emphasis should be placed on prevention and emergency medication.
found IgE antibodies to venom already present, a graduai rise in antibody level during the first two weeks after the sting, or both. Half of a group of patients who had moderate to severe local reactions had elevated levels of IgE antibody to one or more venoms.13 lmmunity
Beekeepers who are very frequently stung tolerate stings well. However, even heavily stung beekeepers report sorne mild local reactions early in the beekeeping season. Later in the season, they may fail to have any demonstrable reaction to stings. By means of a competitive radioimmunoassay we have measured serum total antibodies (primarily IgG) to bee venom (figure 3). Beekeepers often had elevated levels of total antibodies to bee venom while the nonallergic controls did not. There was good correlation between the frequency of stings and the level of such antibodies. 14 Occasionally, allergie patients also have significantly elevated levels of total antibodies to bee venom. Generally, the serum specimens studied are obtained weeks to months after the reaction. When total antibody levels are elevated, they decline over a period of time unless the patient is stung again. In a few cases, when serum has been obtained close to the time ofsting, antibody levels have been undetectable initially. In sorne of the se patients, levels rose in severa! weeks. Treatment
Prevention-Allergie patients should a void locales where stinging insects are prevalent, should never go barefoot outside, and should a void wearing perfumes or bright colors, which may attract bees. An insect repellant should be available but may be of limited bene fit. Medical treatment-Epinephrine is the drug of choice in all anaphylactic reactions. Allergie patients or a responsible relative or friend should be instructed in administration of the appropriate dose (0.01 ml/kg to a
156
maximum of0.3 ml epinephrine 1:1,000 subcutaneously). An allergie patient who has been stung should receive epinephrine immediately and should then be taken to the nearest medical facility. Depending on the situation, the physician may administer antihistamine, steroid, or aminophylline. Maintenance of a patent airway is of great importance. Supportive care should be utilized where indicated. If a stinger is located, it should be flicked off with the fingernail. Care should be taken not to squeeze the venom sac, as addition al venom might be injected. Immunotherapy-For many years, the only material available for immunotherapy has been WBE. Surveys of insect-allergic patients have suggested benefit from this therapy, with most treated patients reporting a less severe reaction after a subsequent sting. However, al most two thirds of untreated patients also did well after a subsequent sting. 3•15 Such studies are at a disadvantage because the same type of insect may not be responsible for both stings and reactions may be masked by medical therapy instituted after the sting. We have reviewed the findings on a group of patients who were observed for up to two years. Most were treated with WBE and the remainder were untreated. The level of IgE antibodies to venom fell in both treated and untreated patients. In another study, total antibodies to bee venom were measured sequentially in 21 bee-sensitive patients treated with WBE. Total antibodies remained at a constant low level in nine patients, fell with time in ten, and rose from undetectable levels to low levels in two. Both of the patients in the last group had been stung a second time and had experienced systemic reactions. We observed total antibody levels in the wife of a beekeeper who was treated with venom after treatment with WBE failed. After venom therapy, total an ti bodies to bee venom rose to levels found in immune beekeepers.
POSTGRADUATE MEDICINE
o
April 1976
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Vol. 59
o
No. 4
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Specifie IgE antibody to bee venom also rose, but the patient was clinically protected when stung again. One of the beekeepers we studied had circulating IgE antibodies to bee venom, which is unusual in protected beekeepers. Her total antibody level was quite high, which may explain her clinical protection. The physician is currently faced with a dilemma with respect to immunotherapy. Circumstantial evidence suggests that immunotherapy with WBE may be of sorne benefit. Our immunologie data do not support this observation. In any event, venom is not generally available for treatment. Until it or sorne other immunologically active material becomes available, greatest emphasis should be placed on prevention and emergency medication. Summary
Immunologie advances promise changes in the approach to diagnosis and treatment of Hymenoptera stings. Results of skin tests with venom show good correlation with those of in vitro tests (histamine release and radioallergosorbent test [RAST]). Similar comparisons of whole-body extract (WBE) skin tests with in vitro tests show po or correlation. Treatment emphasis must currently be
Dr. Light is a fellow in allergy and immunology, and Dr. Reisman is clinical associate professer, department of medicine and pediatries, State University of New York at Buffalo. Wllma C. Light
placed on sting prevention and on medical treatment. The only material now available commercially for immunotherapy is WBE. Circumstantial evidence suggests sorne benefit from immunotherapy with WBE, but immunologie data do not support this observation. • This study was supported in part by US Public Health Service Allergy Clin ica! Centers grant3-P15-Al- 10397 of the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda. Address reprint requests to Robert E. Reisman, MD, Suite 1102 General Medical Towers, 50 High St, Buffalo, NY 14203. ReadySource on allergy appears on page 161. CME Credit Quiz on allergy begins on page 165.
References 1. Barnard JH: Studies of 400 hymenoptera sting deaths in the United States. J Allergy Clin Immunol 52:259-264, 1973 2. Frazier CA: Allergie reactions to insee! stings: A review of 180 cases. South Med J 57:1028-1034, 1964 3. Brown H. Bemton HS: Allergy to hymenoptera. V. Clinical study of 400 patients. Arch Intem Med 125:665-669. 1970 4. Settipane GA, Boyd GK: Prevalence of bee sting allergy in 4,992 boy scouts. Acta Allergol 25:286-291, 1970 5. Chafee FH: The pre valence of bee sting allergy in an allergie population. Acta Allergol 25:292-293, 1970 6. Mue lier HL: Further experiences with severe allergie reactions to insee! stings. N Engl J Med 261:374-377. Aug 1959 7. Parrish HM: Analysis of 460 fatalities from venomous animais in the United States. Am J Med Sei 245:129-141, 1963 8. Benson RL, Semenov H: Allergy in its relation to bee sting. J Allergy Clin Immunol 1:105-116. 1930
Vol. 59
o
No. 4
o
April 1976
o
POSTGRADUATE MEDICINE
9. Benson RL: Diagnosis of hypersensitivity of the bee and of the mosquito. Arch Intern Med 64:1306, 1939 10. Schwartz HJ: Skin sensitivity in insee! allergy. JAMA 194:113-115, 1965 Il. Hunt KJ, Sobotka A, Valentine MD, et al: Diagnosis of hymenoptera hypersensitivity by skin testing with hymenoptera venoms. J Allergy Clin Immunol 55:74, 1975 12. Shulman S. ~igelsen F, Lang R, et al: The allergie response to stinging insects: Biochemical and immunologie studies on bee venom and other bee body preparations. J Immunol 96:29-38. 1966 13. Reisman RE, Arbesman CE: Stinging insee! allergy: Current concepts and problems. Pediatr Clin North Am 22:185-192, 1975 14. Light WC. Reisman RE, Wypych JI, et al: Clinical and immunological studiesofbeekeepers. Clin Allergy 5:389395. 1975 15. Insee! Allergy Committee Report, American Academy of Allergy. 1972 (unpublished)
157
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Stinging insect allergy changing concepts Wilma C. Light & Robert E. Reisman To cite this article: Wilma C. Light & Robert E. Reisman (1976) Stinging insect allergy changing concepts, Postgraduate Medicine, 59:4, 153-157, DOI: 10.1080/00325481.1976.11714333 To link to this article: http://dx.doi.org/10.1080/00325481.1976.11714333
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 12 August 2017, At: 09:34
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
• Allergie reactions following the sting of the bee, yellow jacket, wasp, or bornet are prevalent each summer and fall and account for at least 40 deaths annually in the United States. 1 In ail probability, addition al deaths after insect stings are erroneously attributed to other causes. Recent advances in immunologie techniques have allowed new insight into the pathogenesis of the allergie response to insect stings. Such information may change traditional aspects of diagnosis and treatment. Types of Reactions
A mild local reaction consisting of pain, erythema, and swelling for several centimeters around the site of the sting is the normal response. Swelling subsides in several hours. A moderate to severe local reaction consists of a larger area of swelling than normal, whieh may persist for several days. The swelling may be extensive; for example, a sting on the band might result in swelling to the elbow. Systemie reactions are classieally anaphylactie, usually occur within minutes of the sting, and may be fatal. Symptoms may include angioedema, urticaria, laryngeal edema, bronchospasm, diarrhea, abdominal or uterine cramps, and shock. Taxie reactions are systemie, are induced by multiple stings, and are thought to be due to pharmacologie agents present in the venom. Unusual reactions, often involving the vascular or neurologie system, may follow insect stings (eg, acute glomerulonephritis, serum sickness, Guillain-Barré syndrome). The etiology of such reactions is not known. Certain individuals who essentially have been immunized with venom (eg, beekeepers) may experience no reaction at ali after a bee sting.
stinging insect allergy changing concepts Wilma C. Light, MD Robert E. Reisman, MD State University of New York at Buffalo
consider What immunologie events follow an insect sting? What are the most reliable diagnostic measures for determining whether a person is likely to experience an allergie reaction to an insect sting? How effective is immunotherapy using whole-body extract? Using venom?
Epidemiology
The incidence of acute generalized allergie reactions in the general population has been estimated to be 0.38% to 0.40%. Reactions occur most often in males under the age of 20 years. In our experience with over 400 patients, we have found a ratio of60% males to 40% females. Yellow jacket stings account for more reactions than the stings of other Hymenoptera. 2 - 6 Ali of the foregoing observations can probably be explained
Vol. 59 • No. 4 o April1976 o POSTGRADUATE MEDICINE
153
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
on the basis of opportunity. Children and young people spend more time outdoors than do other age groups, and boys are stung more often than girls. The yellow jacket is fond of food and garbage found at picnics and campsites. Furthermore, its nest is often found in the ground, where it is easily disturbed inadvertently. Ali Hymenoptera will sting to proteot their nest. Most deaths from Hymenoptera stings occur in adults. 1•7 Stings of the head and neck area are more likely to result in systemic reactions than are stings of the extremities, although stings in any area of the body can result in anaphylaxis. About 80% offatalities occur with no apparent prior indication of insect hypersensitivity. ln severa! studies, a time relationship between stings bas not been found. However, we have noted many individuals who reported an uneventful sting two to four weeks prior to the sting that resulted in the systemic reaction. Figure 1. Relative amounts of specifie IgE antibodies to bee venom and whole-bee extract (WBE) in beekeepers, untreated patients, and nonallergic contrais. Relative amounts of IgE antibodies as determined on radioallergosorbent test (RAST) are expressed as a percent of a positive control. Levels greater than 10% are significant.
Figure 2. Distribution of specifie IgE antibodies to bee, yellow jacket, and hornet venom in the serum of 99 insect-allergic patients.
154
Dlagnosls
Because of the pain induced, there is usually little difficulty in relating a sting to a subsequent reaction. Only the bee leaves its stinger in place. Most individuals have difficulty in distinguishing one insect from another, even if they happen to see it. Over 30 years ago, Benson and SemenovB tested a beekeeper with venom and with a whole-body extract (WBE) prepared by grinding the who le insect. The patient reacted to both substances, leading Benson9 to conelude that there is a common allergen found in both venom and bee-body protein. This observation is the foundation for subsequent diagnosis and therapy with WBE. More recent! y, investigators 10•11 have questioned the value of WBE for diagnosis. Skin tests with WBE have failed to produce reactions in patients with very convincing histories of anaphylaxis and have produced reactions in many individuals not sensitive to stings. Experiments by Shulman and colleagues12 with rabbits immunized with venom and WBE suggested that venom contained two antigens, one unique to venom and a
POSTGRADUATE MEDICINE o April1976 o Vol. 59 o No. 4
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
weaker one present also in the WBE. Rabbits immunized with WBE produced an antibody specifie ta WBE which did not react with venom. Therefore, venom and WBE appear ta have separate major antigenic determinants. Hunt and colleagues 11 performed skin tests with venom and WBE on sensitive patients and contrais and compared the results with those of in vitro assessment of histamine release. Leukocytes from sensitive patients were incubated with antigen, and histamine release was measured. Very good correlation was found between the results of venom skin tests and venom-induced histamine release. However, the WBE skin tests failed ta distinguish sensitive patients from contrais. In our laboratory, we compared results of bee-venom skin tests with results of the radioallergosorbent test (RAST), which detects circulating specifie IgE antibodies. Serum from sensitive patients is incubated with antigen attached chemically ta inert cellulose disks. The disks are labeled with radioactive anti-IgE and, after washing, are counted in a gamma counter. The count per minute is proportion al ta the leve! of circulating specifie IgE antibody. We have found very good correlation between results of bee-venom skin tests and bee-venom-specific IgE antibody levels. WBE skin tests were a poor discriminator of patients with positive bee-venom skin tests or elevated circulating venom-specific IgE antibodies. Only half of the patients with bee-venam-specifie IgE had positive WBE skin tests or elevated WBE IgE antibodies. In addition, 10% of nonsensitive patients had false-positive WBE skin tests. These observations confirm the poor reliability of WBE skin tests. Although bee venom has been licensed for testing, it is not commercially available at present. In vitro tests (histamine release and RAST) are excellent substitutes, although they are available at present only in severa! research laboratories. The relative amounts of IgE antibodies ta bee venom and WBE in a group of beekeepers, untreated patients, and nonallergic contrais are compared in figure 1.
Vol. 59 • No. 4 • April 1976 • POSTGRADUATE MEDICINE
Figure 3. Comparison of total antibodies to bee venom in the serum of beekeepers, allergie patients before and after treatment with WBE, and nonallergic contrais. Only 12 of 47 contrais with total antibodies less than 2~o~-g/ml are indicated on chart.
Immunologie Events Followlng a Stlng
Measurable levels of IgE antibody ta venom are not normally found in the serum of nonallergic contrais or in individuals who have been stung without a reaction. IgE antibodies reacting with bee, yellow jacket, or bornet venoms were measured in a large group of insect-sensitive patients. Elevated levels of IgE antibodies ta one or more venoms were found in the vast majority of these patients. Figure 2 shows the distribution of antibodies in 99 insect-sensitive patients. Whether multiple-insect sensitivity results from separate stinging incidents or, more likely, from sorne cross-reactivity between venoms can only be a matter of speculation at present. When sequential serum specimens were available shortly after the time of sting, we
155
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
Until immunologically active material becomes available for the immunotherapy of insect stings, emphasis should be placed on prevention and emergency medication.
found IgE antibodies to venom already present, a graduai rise in antibody level during the first two weeks after the sting, or both. Half of a group of patients who had moderate to severe local reactions had elevated levels of IgE antibody to one or more venoms.13 lmmunity
Beekeepers who are very frequently stung tolerate stings well. However, even heavily stung beekeepers report sorne mild local reactions early in the beekeeping season. Later in the season, they may fail to have any demonstrable reaction to stings. By means of a competitive radioimmunoassay we have measured serum total antibodies (primarily IgG) to bee venom (figure 3). Beekeepers often had elevated levels of total antibodies to bee venom while the nonallergic controls did not. There was good correlation between the frequency of stings and the level of such antibodies. 14 Occasionally, allergie patients also have significantly elevated levels of total antibodies to bee venom. Generally, the serum specimens studied are obtained weeks to months after the reaction. When total antibody levels are elevated, they decline over a period of time unless the patient is stung again. In a few cases, when serum has been obtained close to the time ofsting, antibody levels have been undetectable initially. In sorne of the se patients, levels rose in severa! weeks. Treatment
Prevention-Allergie patients should a void locales where stinging insects are prevalent, should never go barefoot outside, and should a void wearing perfumes or bright colors, which may attract bees. An insect repellant should be available but may be of limited bene fit. Medical treatment-Epinephrine is the drug of choice in all anaphylactic reactions. Allergie patients or a responsible relative or friend should be instructed in administration of the appropriate dose (0.01 ml/kg to a
156
maximum of0.3 ml epinephrine 1:1,000 subcutaneously). An allergie patient who has been stung should receive epinephrine immediately and should then be taken to the nearest medical facility. Depending on the situation, the physician may administer antihistamine, steroid, or aminophylline. Maintenance of a patent airway is of great importance. Supportive care should be utilized where indicated. If a stinger is located, it should be flicked off with the fingernail. Care should be taken not to squeeze the venom sac, as addition al venom might be injected. Immunotherapy-For many years, the only material available for immunotherapy has been WBE. Surveys of insect-allergic patients have suggested benefit from this therapy, with most treated patients reporting a less severe reaction after a subsequent sting. However, al most two thirds of untreated patients also did well after a subsequent sting. 3•15 Such studies are at a disadvantage because the same type of insect may not be responsible for both stings and reactions may be masked by medical therapy instituted after the sting. We have reviewed the findings on a group of patients who were observed for up to two years. Most were treated with WBE and the remainder were untreated. The level of IgE antibodies to venom fell in both treated and untreated patients. In another study, total antibodies to bee venom were measured sequentially in 21 bee-sensitive patients treated with WBE. Total antibodies remained at a constant low level in nine patients, fell with time in ten, and rose from undetectable levels to low levels in two. Both of the patients in the last group had been stung a second time and had experienced systemic reactions. We observed total antibody levels in the wife of a beekeeper who was treated with venom after treatment with WBE failed. After venom therapy, total an ti bodies to bee venom rose to levels found in immune beekeepers.
POSTGRADUATE MEDICINE
o
April 1976
o
Vol. 59
o
No. 4
Downloaded by [Australian Catholic University] at 09:34 12 August 2017
Specifie IgE antibody to bee venom also rose, but the patient was clinically protected when stung again. One of the beekeepers we studied had circulating IgE antibodies to bee venom, which is unusual in protected beekeepers. Her total antibody level was quite high, which may explain her clinical protection. The physician is currently faced with a dilemma with respect to immunotherapy. Circumstantial evidence suggests that immunotherapy with WBE may be of sorne benefit. Our immunologie data do not support this observation. In any event, venom is not generally available for treatment. Until it or sorne other immunologically active material becomes available, greatest emphasis should be placed on prevention and emergency medication. Summary
Immunologie advances promise changes in the approach to diagnosis and treatment of Hymenoptera stings. Results of skin tests with venom show good correlation with those of in vitro tests (histamine release and radioallergosorbent test [RAST]). Similar comparisons of whole-body extract (WBE) skin tests with in vitro tests show po or correlation. Treatment emphasis must currently be
Dr. Light is a fellow in allergy and immunology, and Dr. Reisman is clinical associate professer, department of medicine and pediatries, State University of New York at Buffalo. Wllma C. Light
placed on sting prevention and on medical treatment. The only material now available commercially for immunotherapy is WBE. Circumstantial evidence suggests sorne benefit from immunotherapy with WBE, but immunologie data do not support this observation. • This study was supported in part by US Public Health Service Allergy Clin ica! Centers grant3-P15-Al- 10397 of the National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda. Address reprint requests to Robert E. Reisman, MD, Suite 1102 General Medical Towers, 50 High St, Buffalo, NY 14203. ReadySource on allergy appears on page 161. CME Credit Quiz on allergy begins on page 165.
References 1. Barnard JH: Studies of 400 hymenoptera sting deaths in the United States. J Allergy Clin Immunol 52:259-264, 1973 2. Frazier CA: Allergie reactions to insee! stings: A review of 180 cases. South Med J 57:1028-1034, 1964 3. Brown H. Bemton HS: Allergy to hymenoptera. V. Clinical study of 400 patients. Arch Intem Med 125:665-669. 1970 4. Settipane GA, Boyd GK: Prevalence of bee sting allergy in 4,992 boy scouts. Acta Allergol 25:286-291, 1970 5. Chafee FH: The pre valence of bee sting allergy in an allergie population. Acta Allergol 25:292-293, 1970 6. Mue lier HL: Further experiences with severe allergie reactions to insee! stings. N Engl J Med 261:374-377. Aug 1959 7. Parrish HM: Analysis of 460 fatalities from venomous animais in the United States. Am J Med Sei 245:129-141, 1963 8. Benson RL, Semenov H: Allergy in its relation to bee sting. J Allergy Clin Immunol 1:105-116. 1930
Vol. 59
o
No. 4
o
April 1976
o
POSTGRADUATE MEDICINE
9. Benson RL: Diagnosis of hypersensitivity of the bee and of the mosquito. Arch Intern Med 64:1306, 1939 10. Schwartz HJ: Skin sensitivity in insee! allergy. JAMA 194:113-115, 1965 Il. Hunt KJ, Sobotka A, Valentine MD, et al: Diagnosis of hymenoptera hypersensitivity by skin testing with hymenoptera venoms. J Allergy Clin Immunol 55:74, 1975 12. Shulman S. ~igelsen F, Lang R, et al: The allergie response to stinging insects: Biochemical and immunologie studies on bee venom and other bee body preparations. J Immunol 96:29-38. 1966 13. Reisman RE, Arbesman CE: Stinging insee! allergy: Current concepts and problems. Pediatr Clin North Am 22:185-192, 1975 14. Light WC. Reisman RE, Wypych JI, et al: Clinical and immunological studiesofbeekeepers. Clin Allergy 5:389395. 1975 15. Insee! Allergy Committee Report, American Academy of Allergy. 1972 (unpublished)
157
