Insect allergy Joanna Lange. Epidemiology 0,4 % of the population in the USA;0,4 % of the population...

Insect allergyInsect allergyJoanna LangeJoanna Lange

EpidemiologyEpidemiology

• 0,4 % of the population in the USA;0,4 % of the population in the USA;

• ccrossross -- sectional studiessectional studies::• 11 -- 3% prevalence of systemic reaction3% prevalence of systemic reaction;;• 99 -- 32% sensitization to insect venoms;32% sensitization to insect venoms;

• ddeaths to eaths to Hymenoptera Hymenoptera stings – stings – 40/per year40/per year in the USA; in the USA;

Taxonomy of Taxonomy of HymenopteraHymenopteraFamilyFamily SubfamilySubfamily Scientific nameScientific name Common nameCommon name

ApidaeApidae Apis melliferaApis mellifera

Bombus spp.Bombus spp.

Megabombus spp;.Megabombus spp;.

Pyrobiombus spp.Pyrobiombus spp.

Halictus spp.Halictus spp.

Dialictus spp.Dialictus spp.

HoneybeeHoneybee

BumblebeeBumblebee

SweatbeeSweatbee

VespidaeVespidae VespinaeVespinae

PolistinaePolistinae

Vespula spp.Vespula spp.

Dolichovespula Dolichovespula arenariaarenariaDolichovespula Dolichovespula maculatamaculata

Polistes spp.Polistes spp.

Yellow jacketYellow jacket

Yellow hornetYellow hornet

White-faced White-faced hornethornet

Paper waspPaper wasp

FormicidaeFormicidae Solenopsis invictaSolenopsis invicta

Solenopsis richteriSolenopsis richteri

Pogonomyrmex spp.Pogonomyrmex spp.

Fire antFire ant

Harvester antHarvester ant

Vespa crabro – European hornet

Vespa orientalis

Vespula rufa

Paravespula germanica

Dolichovespula adulteriana

Dolichovespula media

Polistes gallicus

Polistes nimpha

A cluster of honeybee.A cluster of honeybee.

Paper waspPaper wasp

Papernet waspPapernet wasp

In In centralcentral and and northernnorthern EuropeEurope vespid (mainly vespid (mainly Vespula spp.) Vespula spp.) and and honeybee stings are the most prevalent.honeybee stings are the most prevalent.

In the In the MediterraneanMediterranean area stings from area stings from Polistes Polistes and and Vespula Vespula are are more frequent than honeybee stings. more frequent than honeybee stings.

ThThee stinger of honeybees usually remains in human skin. stinger of honeybees usually remains in human skin.

Bumblee-bees and vespids normally remove their stinger from the Bumblee-bees and vespids normally remove their stinger from the human skin.human skin.

Cross - reactivite among Cross - reactivite among HymenopteraHymenoptera

APISAPIS BOMBUSBOMBUS

VESPULAVESPULA

DOLICHOVESPULADOLICHOVESPULA VESPAVESPA CRABROCRABRO

VESPAVESPA ORIENTALISORIENTALISPOLISTESPOLISTES

APIDAEAPIDAE

VESPIDAEVESPIDAE

Venom biochemistryVenom biochemistry


• all venom allergens are proteins, and most are enzymes all venom allergens are proteins, and most are enzymes with molecular weights between 13,000 to 50,000D;with molecular weights between 13,000 to 50,000D;

• with the exeption of with the exeption of mellitinmellitin from honeybee venom, the from honeybee venom, the peptides of peptides of Hymenoptera Hymenoptera venoms are nonallergic but are venoms are nonallergic but are responsible for the toxic and pharmacologies acitvities of responsible for the toxic and pharmacologies acitvities of venom;venom;

• in addition to the proteins and peptides, in addition to the proteins and peptides, Hymenoptera Hymenoptera venoms contain vasoactive amines, such as – histamine, venoms contain vasoactive amines, such as – histamine, 5-hydroxytryptamine, acetylocholine, dopamine and 5-hydroxytryptamine, acetylocholine, dopamine and norepinephrinenorepinephrine

• within the yellow jacket family there is strong cross - within the yellow jacket family there is strong cross - antigenicity and cross –allergenicity among venoms from antigenicity and cross –allergenicity among venoms from V. V. maculifrons, V.germanica, V.vulgaris maculifrons, V.germanica, V.vulgaris and and V.flavopilosa;V.flavopilosa;

• similar findings have been reported for the paper wasp similar findings have been reported for the paper wasp family;family;

• there are rare individuals who react only to venom from one there are rare individuals who react only to venom from one vespid species;vespid species;

• there is little or no cross – reactivity between honeybee there is little or no cross – reactivity between honeybee venom phospholipase A and vespid venom phospholipase A, venom phospholipase A and vespid venom phospholipase A, whereas hyaluronidase from bee and vespid venom may whereas hyaluronidase from bee and vespid venom may cross - react.cross - react.


Bee venomBee venom

Substances of lower molecular weight:Substances of lower molecular weight:feromones, feromones, histamin -local toxity,histamin -local toxity, dopamin, norepinephrine, dopamin, norepinephrine, aminoacides, oligopeptides, fosfolipids, węglowodany;aminoacides, oligopeptides, fosfolipids, węglowodany;

Bigger peptides -1000-5000:Bigger peptides -1000-5000:mellitin – membrane poisson; apamin - neurotoxin;mellitin – membrane poisson; apamin - neurotoxin;Peptide - MCD, tertiapine - liberator of histamin;Peptide - MCD, tertiapine - liberator of histamin;secapine; kardiopeptide – secapine; kardiopeptide – positive inotropic and chronotropic;positive inotropic and chronotropic;

Enzymes - 10000 do 200000:Enzymes - 10000 do 200000:phospholipase A2 - membrane poisson – phospholipase A2 - membrane poisson – very high alergogenityvery high alergogenity;;hyaluronidase – hyaluronidase – high alergogenityhigh alergogenity; acid phosphatase;; acid phosphatase;alfa-glukosidase; esterases;alfa-glukosidase; esterases;

Another:Another:adolapin – pain relief, alergen C;adolapin – pain relief, alergen C;


Bombus venomBombus venom

phospholipasa A2; hialuronidase; acid phospholipasa A2; hialuronidase; acid

phosphatase;phosphatase;

Immunological mimikra to bee venomImmunological mimikra to bee venom


Vespa venomVespa venom• histamin – higher than bee venom;histamin – higher than bee venom;• serotonin;serotonin;• acetylocholin;acetylocholin;• kinines;kinines;• mastoparan – mastoparan – degranulates mast cells;degranulates mast cells;• hemolizyn - hemolizyn - mellitin – like;mellitin – like;• phospholipase A i B;phospholipase A i B;• hialuronidases;hialuronidases;• antigen 5;antigen 5;

Allergens activity - Allergens activity - phospholipases, hialuronidase i phospholipases, hialuronidase i antigen 5;antigen 5;


Clinical presentation and Clinical presentation and pathogenesis of sting pathogenesis of sting

reactionsreactions

Clinical presentationClinical presentation

• venom hypersensitivity may be mediated venom hypersensitivity may be mediated by by immunologicimmunologic mechanisms (IgE or not- mechanisms (IgE or not-IgE), but also by IgE), but also by non - immunologicalnon - immunological mechanisms;mechanisms;

• classification if the reaction:classification if the reaction:• normal local reaction;normal local reaction;• large local reaction;large local reaction;• systemic toxic reaction;systemic toxic reaction;• systemic anaphzlactic reaction;systemic anaphzlactic reaction;• unusual reaction.unusual reaction.

Normal local sting reactionNormal local sting reaction

• local reaction with pain;local reaction with pain;

• erythema;erythema;

• slight swelling around the sting side;slight swelling around the sting side;

• subside within 24 hours;subside within 24 hours;

• only a small sting reaction may be remain only a small sting reaction may be remain a visible for a few days.a visible for a few days.


Large local sting reactionLarge local sting reaction (LLR)(LLR)

• swelling exceeding a diameter of 10 cm swelling exceeding a diameter of 10 cm last longer than 24 hours;last longer than 24 hours;

• blisters may be rarely present;blisters may be rarely present;

• sometimes swollen lymph glands;sometimes swollen lymph glands;

• great discomfortgreat discomfort when symptoms when symptoms prolproloonged few daysnged few days;;


Systemic anaphylactic reactionSystemic anaphylactic reaction

• most often IgE - mediated;most often IgE - mediated;• non - IgE mediated reaction - due to short term non - IgE mediated reaction - due to short term

sensitising IgG or complement activation by IgG-sensitising IgG or complement activation by IgG-venom complexes;venom complexes;

• most often symptoms appear within few minutes most often symptoms appear within few minutes after the sting;after the sting;

• recovering few hours after stinging;recovering few hours after stinging;


Classification of systemic reaction to Classification of systemic reaction to insect sting by H.L. Muellerinsect sting by H.L. Mueller

Grade IGrade I Generalized urticaria, itching, malaise and anxietyGeneralized urticaria, itching, malaise and anxiety

Grade IIGrade II Any of the above plus two of more of the following: Any of the above plus two of more of the following: angioedema, chest constriction, nausea, vomiting, angioedema, chest constriction, nausea, vomiting, diarrhea, abdominal pain, dizzinessdiarrhea, abdominal pain, dizziness

Grade IIIGrade III Any of the above plus two of more of the following:Any of the above plus two of more of the following: dyspnea, whezzing, stridor, dysarthria, hoarsness, dyspnea, whezzing, stridor, dysarthria, hoarsness, weakness, confusion, feeling of impending disasterweakness, confusion, feeling of impending disaster

Grade IVGrade IV Any of the above plus two of more of the following:Any of the above plus two of more of the following: fall fall in blood pressure, collapse, loss of conciousness, in blood pressure, collapse, loss of conciousness, incontinence, cyanosisincontinence, cyanosis

Classification of systemic reaction modifide Classification of systemic reaction modifide according to J. Ring and Messmeraccording to J. Ring and Messmer

Grade IGrade I Generalized Generalized skin symptoms (e.g. flush, generalised skin symptoms (e.g. flush, generalised urticaria, urticaria, angioedema)angioedema)

Grade IIGrade II Mild to moderate pulmonary, cardiovascular, and/or Mild to moderate pulmonary, cardiovascular, and/or gastrointestinal symptomsgastrointestinal symptoms

Grade IIIGrade III Anaphylactic shock, loss of conciousnessAnaphylactic shock, loss of conciousness

Grade IVGrade IV Cardiac arrest, apnoeaCardiac arrest, apnoea

Systemic toxic reactionSystemic toxic reaction

• toxic effecttoxic effect – phospholipase and – phospholipase and hyaluronidase;hyaluronidase;

• after after multiplemultiple – usually 50 -100 stings; – usually 50 -100 stings;• symptoms:symptoms: rhabdomyolisis, myocardial damage, rhabdomyolisis, myocardial damage,

hepatic dysfunction, intravascular haemolysis, acute hepatic dysfunction, intravascular haemolysis, acute renal failure, coagulation disorders with bleeding and renal failure, coagulation disorders with bleeding and DIC;DIC;


Unusual reactionUnusual reaction

• serum sikness like symptoms with fever, serum sikness like symptoms with fever, arthralgias, urticaria, angioedema, arthralgias, urticaria, angioedema, lymphadenopathy and neurological symptoms;lymphadenopathy and neurological symptoms;

• gromeluronephritis, acute allergic renal nephritis, gromeluronephritis, acute allergic renal nephritis, haemolytic anemia, thrombocytopenia, haemolytic anemia, thrombocytopenia, myocarditis, Guillain-Barre sydromemyocarditis, Guillain-Barre sydrome


DiagnosisDiagnosis

• history;history;

• skin tests;skin tests;

• in vitro tests;in vitro tests;

• allergen specific IgG;allergen specific IgG;

• baseline serum tryptase;baseline serum tryptase;

• other in vitro testsother in vitro tests

• Diagnostic tests should be done in all patients Diagnostic tests should be done in all patients with a history of a systemic sting reaction to with a history of a systemic sting reaction to detect sensitisation;detect sensitisation;

• Diagnostic tests are not recommended in Diagnostic tests are not recommended in subjects with a history of large local reaction or subjects with a history of large local reaction or no history of a systemic reaction;no history of a systemic reaction;

• Testing comprises skin tests with Testing comprises skin tests with Hymenophtera Hymenophtera venoms and analysis of the serum for venoms and analysis of the serum for Hymenophtera Hymenophtera venom-specific IgE;venom-specific IgE;

• Stepwise skin testing with incremental venom Stepwise skin testing with incremental venom concentrations is recommended;concentrations is recommended;

• If skin prick tests are negative subsequently If skin prick tests are negative subsequently intradermal tests should be done;intradermal tests should be done;

• If diagnostic tests are negative they should be If diagnostic tests are negative they should be repeated several weeks later;repeated several weeks later;

• If both skin tests and specific Ige stay negative If both skin tests and specific Ige stay negative additional in-vitro tests should be carried out;additional in-vitro tests should be carried out;

• Serum tryptase should be analysed in patients Serum tryptase should be analysed in patients with a history of a severe sting reactionwith a history of a severe sting reaction

PreventionPrevention

Preventing insect stings and bites

• Avoid provoking insects whenever possible. Avoid provoking insects whenever possible.

• Avoid rapid, jerky movements around insect hives or nests. Avoid rapid, jerky movements around insect hives or nests.

• Avoid perfumes and floral-patterned or dark clothing. Avoid perfumes and floral-patterned or dark clothing.

• Use appropriate insect repellants and/or protective clothing. Use appropriate insect repellants and/or protective clothing.

• Use caution when eating outdoors, especially with sweetened Use caution when eating outdoors, especially with sweetened beverages or in beverages or in areas around garbage cans which often attract areas around garbage cans which often attract bees. bees.

Examples of activities implying special risk Examples of activities implying special risk for stings during warm seasonfor stings during warm season

• outdoor eating and drinking;outdoor eating and drinking;• barefoot walking;barefoot walking;• gardening (especially cutting hedges, flowers);gardening (especially cutting hedges, flowers);• picking fruit;picking fruit;• outdoor sporting (especially with scanty outfit or outdoor sporting (especially with scanty outfit or

open mouth);open mouth);• staying close to beehives when honey is staying close to beehives when honey is

collected;collected;• removing vespid nests from attic or windows;removing vespid nests from attic or windows;

Yellow jacket and Vespa crabro nestYellow jacket and Vespa crabro nest

Emergency treatmentEmergency treatment

YESYES

Removing of the stinger

NO

Technic of proper removing of Technic of proper removing of the stingerthe stinger

First aid for minor reactions

• If the sting is from a honey bee, remove the stinger from the skin if it is If the sting is from a honey bee, remove the stinger from the skin if it is still still present. Carefully scrape the back of a knife or other thin straight-present. Carefully scrape the back of a knife or other thin straight-edged object across the stinger if the victim can remain still, and it is edged object across the stinger if the victim can remain still, and it is safe to do so. Otherwise, you can pull out the stinger with tweezers safe to do so. Otherwise, you can pull out the stinger with tweezers or your fingers, but avoid pinching the venom sac at the end of the or your fingers, but avoid pinching the venom sac at the end of the stinger which will cause more venom to be released. stinger which will cause more venom to be released.

• Wash the site thoroughly with soap and water. Wash the site thoroughly with soap and water.

• Cover the site with a clean, cold compress or a clean, moist dressing to Cover the site with a clean, cold compress or a clean, moist dressing to reduce swelling and discomfort. reduce swelling and discomfort.

• Over the next 24 to 48 hours, observe the site for signs of infection Over the next 24 to 48 hours, observe the site for signs of infection (such as increasing redness, swelling, pain). (such as increasing redness, swelling, pain).

• Sores from scratching can become infected. Keep bites clean and, to Sores from scratching can become infected. Keep bites clean and, to prevent infection, don't scratch. prevent infection, don't scratch.

First aid for serious reactionsIf the victim is having a severe reaction or the victim has been stung inside the mouth or throat, call immediately for emergency medical assistance.

•Check the victim’s airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.

•Reassure the victim. Try to keep him or her calm, as anxiety will worsen the situation.

•Remove nearby rings and constricting items because the affected area may swell.

•Use a special allergy first aid kit, if available. (Some people who have serious insect reactions carry it with them.)

•If appropriate, treat the victim for signs of shock. Remain with the victim until medical help arrives.

Treatment of systemic reaction to Treatment of systemic reaction to Hymenoptera Hymenoptera stingsting

Type of reactionType of reaction Drug and doseDrug and dose NotesNotes

Mild urticariaMild urticaria Antihistamines oral or parenteralAntihistamines oral or parenteral Observe for at least 60 Observe for at least 60 minutesminutes

Urticaria, angioedemaUrticaria, angioedema Check blood pressure and pulse Check blood pressure and pulse raterate

Establish an i.v. line with salineEstablish an i.v. line with saline

Antihistamines oral or parenteralAntihistamines oral or parenteral

Corticosteroids oral or parenteralCorticosteroids oral or parenteral

In case of severe or progressive In case of severe or progressive symptoms:symptoms:

Epinephrine (1mg/ml):Epinephrine (1mg/ml):

- Adults 0,30 – 0,50 mg i.m.- Adults 0,30 – 0,50 mg i.m.

- Children 0,01 ml/kg i.m.- Children 0,01 ml/kg i.m.

Patient must be kept Patient must be kept under observation until under observation until symptoms completely symptoms completely disappeardisappear


Type of reactionType of reaction Drug and doseDrug and dose NotesNotes

Laryngeal oedemaLaryngeal oedema Epinephrine by inhalation or i.m.Epinephrine by inhalation or i.m. Intubation, Intubation, tracheotomy or tracheotomy or cricothyrotomy may be cricothyrotomy may be needed in cases of needed in cases of more severe laryngeal more severe laryngeal oedemaoedema

Bronchial obstructionBronchial obstruction Mild to moderate – beta2 –agonists Mild to moderate – beta2 –agonists by inhalationby inhalation

Severe - Epinephrine by inhalation Severe - Epinephrine by inhalation

beta2 –agonists (0,5 mg/ml) 1 beta2 –agonists (0,5 mg/ml) 1 year- 0,05 – 0,1 mg; 7 years- 0,2 -year- 0,05 – 0,1 mg; 7 years- 0,2 -0,4 mg; adults 0,25-0,5 mg0,4 mg; adults 0,25-0,5 mg

All patients with All patients with protracted respiratory protracted respiratory symptoms must be symptoms must be hospitalized; those hospitalized; those with laryngeal oedema with laryngeal oedema must be given must be given intensive medical care intensive medical care as soon as possibleas soon as possible


Type of Type of reactionreaction

Drug and doseDrug and dose NotesNotes

Anaphylactic shockAnaphylactic shock Epinephrine (1mg/ml):Epinephrine (1mg/ml):

- Adults 0,30 – 0,50 mg i.m.- Adults 0,30 – 0,50 mg i.m.

- Children 0,01 ml/kg i.m.- Children 0,01 ml/kg i.m.

May be repeated after 5-15 min.May be repeated after 5-15 min.

Exeptionally i.v.Exeptionally i.v.

Place patient in supine position, oxygen 5-10 Place patient in supine position, oxygen 5-10 l/minl/min

Check blood pressure and pulse rateCheck blood pressure and pulse rate

i.v.access, volume replacementi.v.access, volume replacement

Antihistamines i.v. corticoids i.v.Antihistamines i.v. corticoids i.v.

Dopamine or norepinephrine infusionDopamine or norepinephrine infusion

Glucagone:0,1 mg/kg i.v (nausea, vomiting)Glucagone:0,1 mg/kg i.v (nausea, vomiting)

Hospitalization necessarz Hospitalization necessarz because of the risk of because of the risk of delazed anaphylaxisdelazed anaphylaxis

If epinephrine injections with If epinephrine injections with or without antihistamines and or without antihistamines and volume expansion fail to volume expansion fail to alleviate hypotensionalleviate hypotension

For refractory hypotension For refractory hypotension and bronchospasm in and bronchospasm in patients on beta-blokerspatients on beta-blokers

Epinephrine - indicationsEpinephrine - indications

• all with history of anaphylaxis or „ very sensitized”;all with history of anaphylaxis or „ very sensitized”;

• those with hymenophtera allergy;those with hymenophtera allergy;

• with food allergy;with food allergy;

• in patients with anaphylaxis induced by exercises;in patients with anaphylaxis induced by exercises;

Emergency treatmentEmergency treatment

• after a systemic reation, patients should be referred to after a systemic reation, patients should be referred to an allergy specialist for evaluation of their allergy and an allergy specialist for evaluation of their allergy and if necessary VIT;if necessary VIT;

• i.m. epinephrine is regarded as a treatment fo choice i.m. epinephrine is regarded as a treatment fo choice for acute anaphylaxis;for acute anaphylaxis;

• H1 – antihistamines alone or in combination with H1 – antihistamines alone or in combination with corticosteroids may be efective in mild to moderate, corticosteroids may be efective in mild to moderate, reactions confined to the skin and may support the reactions confined to the skin and may support the value of treatment with epinephrine in full-blown value of treatment with epinephrine in full-blown anaphylaxis;anaphylaxis;

• untreated patients with a history of a systemic reaction untreated patients with a history of a systemic reaction are strongly advised to carry emergency kits are strongly advised to carry emergency kits containing injectable epinephrine for self containing injectable epinephrine for self administrationadministration

Proper using Proper using of EpiPenof EpiPen

Remove the device from the plastic protective container.

Remove the Remove the greygrey cap cap from the from the fatter end of the device.fatter end of the device.

NBNB: This "arms the unit" ready : This "arms the unit" ready for usefor use

HoldHold the EpiPen in your fist with clenched fingers wrapped around it the EpiPen in your fist with clenched fingers wrapped around it((NBNB: there is nothing to "push" at the white end): there is nothing to "push" at the white end)

Press the Press the black tipblack tip gently against the skin of the mid thigh, then start to gently against the skin of the mid thigh, then start to push harder until a loud "click" is heard. This means that the device push harder until a loud "click" is heard. This means that the device

has been activated.has been activated.

Hold in place for 10-15 seconds (count "1 elephant, 2 elephants, 10 Hold in place for 10-15 seconds (count "1 elephant, 2 elephants, 10 elephants etc") while the adrenaline is injected under pressure.elephants etc") while the adrenaline is injected under pressure.

NBNB: The EpiPen "pop" is often quite loud.: The EpiPen "pop" is often quite loud.

RemoveRemove the pen from the thigh; be careful with the needle the pen from the thigh; be careful with the needle that will now be projecting from the EpiPen when you that will now be projecting from the EpiPen when you

dispose of the device.dispose of the device.MassageMassage in the adrenalin. There may be some slight in the adrenalin. There may be some slight

bleeding at the injection site.bleeding at the injection site.

Apply firm pressure with a cloth, tissue, clean handkerchief Apply firm pressure with a cloth, tissue, clean handkerchief or bandage.or bandage.

RecordRecord the time that the EpiPen was given. the time that the EpiPen was given.

Call for help.Call for help.

EpiPen Mistakes- what not to do!

MISTAKE NUMBER 1MISTAKE NUMBER 1

The black tip contains the needle and The black tip contains the needle and needs to be placed against the mid-thigh.needs to be placed against the mid-thigh.Holding the wrong end and injecting the Holding the wrong end and injecting the thumb (blue line) is painful and not very thumb (blue line) is painful and not very

effective ...effective ...


Unless the grey cap is removed (Unless the grey cap is removed (blue lineblue line), ), the EpiPen will NOT work, no matter how the EpiPen will NOT work, no matter how

hard you push ...hard you push ...


This photograph is more subtle. The patient is This photograph is more subtle. The patient is pressing the white end very hard (pressing the white end very hard (blue lineblue line), ),

assuming there is a "button" at the white end. assuming there is a "button" at the white end. There is not!There is not!

Unless pressure is exerted at the black end, the Unless pressure is exerted at the black end, the EpiPen will not work. By all means rest the thumb EpiPen will not work. By all means rest the thumb on the white end, but you must exert pressure on on the white end, but you must exert pressure on

the black tip into the thigh as well.the black tip into the thigh as well.

Epi MateEpi Mate

www. medicareplus.co.uk

40 €30 €

35 €

35 35 €€

First aid kit

Venom Venom immunotherapyimmunotherapy

Venom immunotherapyVenom immunotherapy

Indications:Indications:• in persons who have expirience a systemic reaction to in persons who have expirience a systemic reaction to

an insect sting and who have postive skin test (prick or an insect sting and who have postive skin test (prick or intradermal) at concentration 1 mcg/ml or less;intradermal) at concentration 1 mcg/ml or less;

• medical indications are strongest in medical indications are strongest in adultsadults – untreated – untreated individuals – 50-60% of risk of systemic reaction if stung individuals – 50-60% of risk of systemic reaction if stung again;again;

• large local reactionslarge local reactions – only a small risk of anaphylaxix – only a small risk of anaphylaxix after future stingsafter future stings


Contra indications:Contra indications:

• autoimmunologic diseases;autoimmunologic diseases;• tumors;tumors;• immunological deficiences;immunological deficiences;• children younger than 5 years;children younger than 5 years;• insufficiences of heart, hepatic problems, nephrological insufficiences of heart, hepatic problems, nephrological

problems, epilepsy;problems, epilepsy;• psychiatric problems;psychiatric problems;• diseases in which adrenalin is conrtaindicated (e.g. diseases in which adrenalin is conrtaindicated (e.g.

pcheochromocytoma, thyreoid tumors);pcheochromocytoma, thyreoid tumors);

Indication to the immunotherpy (byIndication to the immunotherpy (by Bousquet Bousquet)) in in patients abovepatients above 15 15 year year

Clinical reaction

Skin tests IgE Qualification for IT

Systemic reactions

+ + +

Systemic reactions

+ - +

Systemic reactions

- + disussion

Systemic reactions

- - 0

Local reactions

+ or - + or - 0

Indication to the immunotherpy (byIndication to the immunotherpy (by Bousquet Bousquet)) in in patients younger thanpatients younger than 15 15 year year

Clinical reaction

Skin tests IgE Qualification for IT

Systemic reactions

+ + +

Systemic reactions

+ - +

Systemic reactions

- + disussion

Systemic reactions

- - 0

Generalized urticaria

+ + usually 0

Local reactions

+ or - + or - 0

Even skin tests are positive or specific IgE Even skin tests are positive or specific IgE are positive, no immunotherapy in such are positive, no immunotherapy in such

situationssituations::

• no systemic or large local reactionsno systemic or large local reactions;;

• only slight large local reactiononly slight large local reaction;;

• systemic reactions were latesystemic reactions were late;;

SchedulesSchedules• it is possible to reach the targeted maintance dose it is possible to reach the targeted maintance dose

(100 mcg/ml) in 2 or 3 days, 6 hours or even 3(100 mcg/ml) in 2 or 3 days, 6 hours or even 311//22 hourse;hourse;

• local swelling, erythema or even anaphylactic local swelling, erythema or even anaphylactic reactions – those schedules unacceptable for some reactions – those schedules unacceptable for some persons;persons;

• if monthly maintance doses of venom have been if monthly maintance doses of venom have been tolerates fo 6 months, the interval between injections tolerates fo 6 months, the interval between injections can be lenghted to 6 to 8 weeks or 8 to 12 weeks;can be lenghted to 6 to 8 weeks or 8 to 12 weeks;


SafetySafety• generally well tolerated;generally well tolerated;

• 12% of persons have allergic reactions during the bulid 12% of persons have allergic reactions during the bulid – up doses of 1 to 50 mcg/ml and some in the – up doses of 1 to 50 mcg/ml and some in the maintance dose of 100 mcg; maintance dose of 100 mcg;

• more apt to occur with honeybee or wasp more apt to occur with honeybee or wasp immunotherapy;immunotherapy;

• if a patient experiences a systemic reaction during if a patient experiences a systemic reaction during bulid-up phase, the next dose should be reduced by bulid-up phase, the next dose should be reduced by 50%50%


Bitting insect allergyBitting insect allergy

Selected biting insects reported to cause human Selected biting insects reported to cause human allergic reactionsallergic reactions

OrderOrder FamilyFamily GenusGenus

HemipteraHemiptera ReduvidiidaeReduvidiidae

Cimicidae (bed bugs)Cimicidae (bed bugs)

Triatoma Triatoma (kissing or cone-(kissing or cone-nose bug)nose bug)

CimexCimex

DipteraDiptera Culicidae (mosquitos)Culicidae (mosquitos)

Simuliidae (blackfly)Simuliidae (blackfly)

TabanidaeTabanidae

CulexCulex

AedesAedes

AnophelesAnopheles

CulisetaCuliseta

CnephiaCnephia

ProsimuliumProsimulium

SimuliumSimulium

Tabanus Tabanus (horsefly)(horsefly)

Chrysops Chrysops (deerfly)(deerfly)

SiphonapteraSiphonaptera PulicidaePulicidae Ctenocephalides Ctenocephalides (cat or (cat or dog flea)dog flea)

Triatoma (Kissing bug, Cone – nose bug)Triatoma (Kissing bug, Cone – nose bug)

• feed by sucking the blood of vertebrate animals;feed by sucking the blood of vertebrate animals;

• bites are painless;bites are painless;

• allergens derived from salivary glands of insect;allergens derived from salivary glands of insect;

• immunotherapy with immunotherapy with T.protracta T.protracta salivary gland salivary gland extract has provided clinical protection from extract has provided clinical protection from Triatoma Triatoma bite – induced anaphylaxis in a small bite – induced anaphylaxis in a small number of individuals;number of individuals;

Culicidae (Mosquitoes)Culicidae (Mosquitoes)

• severe local reactions;severe local reactions;

• anaphylacitic reactions are anegdotal;anaphylacitic reactions are anegdotal;

• cutaneous reactions may be mediate by cutaneous reactions may be mediate by IgE antibodies to mosquito salivary IgE antibodies to mosquito salivary proteins;proteins;

Tabanidae (Horsefly, Deerflies)Tabanidae (Horsefly, Deerflies)• females suck blood, whereas males feed on plant juices, females suck blood, whereas males feed on plant juices,

nectar or other nourishing liquids;nectar or other nourishing liquids;

• Horseflies are cosmopolitan and are pests of both human Horseflies are cosmopolitan and are pests of both human and animals;and animals;

• their bite is painful, and they make a deep wound with a their bite is painful, and they make a deep wound with a considerable flow of blood;considerable flow of blood;

• systemic reactions have been noted after deerfly bites and systemic reactions have been noted after deerfly bites and IgE antibodies to deerfly antigens have been demonstrated IgE antibodies to deerfly antigens have been demonstrated by leukocyte histamine release assays and passive skin by leukocyte histamine release assays and passive skin testing;testing;

Other biting insectsOther biting insects

• only two case reports of allergic reactions after only two case reports of allergic reactions after bites from bed bugs bites from bed bugs (Cimex spp(Cimex spp.);.);

• blackfly bites may cause large local reactions and blackfly bites may cause large local reactions and induce specific IgE antibodies;induce specific IgE antibodies;

• severe systemic reactions to blackfly bites are severe systemic reactions to blackfly bites are rare;rare;

Inhalant insect allergyInhalant insect allergy

• rhinitis, conjunctivitis, and asthma can develop rhinitis, conjunctivitis, and asthma can develop as the result of allergic sensitivity to scales, as the result of allergic sensitivity to scales, hairs, and emanations of a variety of insects;hairs, and emanations of a variety of insects;

• symptoms are typical of inhalant allergy caused symptoms are typical of inhalant allergy caused by other activities to polens and danders;by other activities to polens and danders;

• a number of insects may cause occupational a number of insects may cause occupational asthma (e.g. coackroaches)asthma (e.g. coackroaches)

Insect allergy Joanna Lange. Epidemiology 0,4 % of the population in the USA;0,4 % of the population...

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Transcript of Insect allergy Joanna Lange. Epidemiology 0,4 % of the population in the USA;0,4 % of the population...