Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD,...

57
Stinging Insect Allergy Barnstable County Barnstable County Beekeepers Beekeepers Association Association April 12, 2011 April 12, 2011 Bruce R. Gordon, MD, FACS, Bruce R. Gordon, MD, FACS, FAAOA FAAOA Harvard Clinical Instructor Harvard Clinical Instructor President, American Academy of President, American Academy of Otolaryngic Allergy, 2002-2003 Otolaryngic Allergy, 2002-2003

Transcript of Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD,...

Page 1: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Stinging Insect AllergyStinging Insect AllergyBarnstable CountyBarnstable County

Beekeepers AssociationBeekeepers Association April 12, 2011April 12, 2011

Bruce R. Gordon, MD, FACS, FAAOABruce R. Gordon, MD, FACS, FAAOAHarvard Clinical InstructorHarvard Clinical Instructor

President, American Academy of Otolaryngic President, American Academy of Otolaryngic Allergy, 2002-2003Allergy, 2002-2003

Page 2: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

ObjectivesObjectives

Learn to :• Understand sting reaction types• Recognize responsible insects• Understand risk factors• Understand basic treatment of stings• Understand when and how to immunize• Understand when to stop immunotherapy

Learn to :• Understand sting reaction types• Recognize responsible insects• Understand risk factors• Understand basic treatment of stings• Understand when and how to immunize• Understand when to stop immunotherapy

Page 3: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Type of Reactions to BeesType of Reactions to Bees• Contact allergy to propolis

• Respiratory allergy to hive dust and bee bodies

• Asthma and anaphylaxis from royal jelly

• Sting reactions:– Toxic reactions

– Local reactions

– Systemic Anaphylacic reactions

• Contact allergy to propolis

• Respiratory allergy to hive dust and bee bodies

• Asthma and anaphylaxis from royal jelly

• Sting reactions:– Toxic reactions

– Local reactions

– Systemic Anaphylacic reactions

Bousquet J, Menardo JL, Michel FB. Allergy in beekeepers.Allergol Immunopathol (Madr). 1982;10(5):395-8.

Page 4: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

EpidemiologyEpidemiology• 26.5% U.S. prevalence of venom sensitization

(27.1% in Germany)

• > 0.5 to 5% U.S. Severe insect sting allergy

• > 40 deaths / year U.S. from insect stings

– (does not include suspicious sudden deaths)

• 26.5% U.S. prevalence of venom sensitization

(27.1% in Germany)

• > 0.5 to 5% U.S. Severe insect sting allergy

• > 40 deaths / year U.S. from insect stings

– (does not include suspicious sudden deaths)

1. Neugut AI, Ghatak AAT, Miller RRL. Anaphylaxis in the United States: an investigation into its epidemiology. Arch Intern Med. 2001;161(1):15-21.

2. Schäfer TT, Przybilla BB. IgE antibodies to Hymenoptera venoms in the serum are common in the general population and are related to indications of atopy. Allergy. 1996;51(6):372-7.

3. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hypersensitivity. JAMA 1987; 258:2881-2885

Page 5: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Sensitization Riskfrom Stings

Sensitization Riskfrom Stings

• Frequent stings, especially < 2 mo. apart, sensitize

• Very frequent stings, > 50 / yr, desensitize (beekeepers)

• Frequent stings, especially < 2 mo. apart, sensitize

• Very frequent stings, > 50 / yr, desensitize (beekeepers)

Pucci S, Antonicelli L, Bilo MB, Garritani MS, Bonifazi F. Pucci S, Antonicelli L, Bilo MB, Garritani MS, Bonifazi F. Shortness of interval between two stings as risk factor for Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy. 1994;49:894-6developing Hymenoptera venom allergy. Allergy. 1994;49:894-6

Page 6: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Types of Stinging InsectsTypes of Stinging Insects

Stinging insects are order Hymenoptera (membrane-winged insects)

• Apids (honeybees and bumblebees)

• Vespids (yellow jackets, wasps,

hornets, and paper wasps)

• Formicids (ants, fire ants)

Stinging insects are order Hymenoptera (membrane-winged insects)

• Apids (honeybees and bumblebees)

• Vespids (yellow jackets, wasps,

hornets, and paper wasps)

• Formicids (ants, fire ants)

Page 7: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Hymenoptera: Apids (Bees)

Risk of being Stung

Hymenoptera: Apids (Bees)

Risk of being Stung• Domestic honeybees do not sting unless provoked

• Bumblebees are not aggressive & rarely sting, but

use in greenhouses increases exposure

• Africanized hybrid honeybees, common in Mexico

and South, are hostile, aggressive, and swarm

• Domestic honeybees do not sting unless provoked

• Bumblebees are not aggressive & rarely sting, but

use in greenhouses increases exposure

• Africanized hybrid honeybees, common in Mexico

and South, are hostile, aggressive, and swarm

Page 8: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Africanized Bees 2009 RangeAfricanized Bees 2009 Range

Page 9: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• Bees leave their barbed stinger and venom sac implanted in their victim

• This distinguishes honeybee stings from all other stings: bumblebees, wasps, and ants have no barbs

• Bees leave their barbed stinger and venom sac implanted in their victim

• This distinguishes honeybee stings from all other stings: bumblebees, wasps, and ants have no barbs

Honeybee Stinger

is Barbed

Honeybee Stinger

is Barbed

Page 10: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Honeybee stings,then

leaves

Honeybee stings,then

leaves

Page 11: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Alarm pheromones evaporate from stings, attracting other

bees to the victim

Alarm pheromones evaporate from stings, attracting other

bees to the victimLewis,FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007;79:439-44

Page 12: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Honeybee venom is very sensitizing–More likely to react on re-sting–More likely to react during

immunotherapy treatments–Less likely to be protected by

immunotherapy–Less likely to stop immunotherapy

Honeybee venom is very sensitizing–More likely to react on re-sting–More likely to react during

immunotherapy treatments–Less likely to be protected by

immunotherapy–Less likely to stop immunotherapy

Honeybee Sting AllergyHoneybee Sting Allergy

Graft DF. Venom immunotherapy: when to start, when to stopAllergy Asthma Proc. 2000; 21:113-116

Page 13: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Africanized Bee StingsAfricanized Bee Stings

• Africanized bees and domestic bees have identical venoms

• Africanized bees are much more dangerous due to easy arousal, aggressive stinging, mass stings, and persistent pursuit of the victim

• Africanized bees and domestic bees have identical venoms

• Africanized bees are much more dangerous due to easy arousal, aggressive stinging, mass stings, and persistent pursuit of the victim

Lewis,FS, Smith, LJ. What’s eating you? Bees, part 1. Cutis 2007;79:439-44

Page 14: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Bumble Bee Stings

Bumble Bee Stings

• Ground nesting, < 200 bees per nest

• Stinger not barbed: stings repeatedly

• Not easily irritated: stings uncommon

• Ground nesting, < 200 bees per nest

• Stinger not barbed: stings repeatedly

• Not easily irritated: stings uncommon

Page 15: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Hymenoptera: Vespids (Wasps)Hymenoptera: Vespids (Wasps)

• Yellow Jackets: ground nesting; very aggressive & swarm - stings cause skin infection

• Hornets, Wasps, and Paper Wasps : aerial nesting - in trees, roof overhangs, shutters, under shingles, in attics; not aggressive unless disturbed

• Yellow Jackets: ground nesting; very aggressive & swarm - stings cause skin infection

• Hornets, Wasps, and Paper Wasps : aerial nesting - in trees, roof overhangs, shutters, under shingles, in attics; not aggressive unless disturbed

Page 16: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Imported Fire Ants found in SE and Gulf coast; will spread much further north & west from global warming

Ants bite, and deliver multiple stings in circular pattern; aggressive & swarm - attacks 6 - 60% of people living in an area during each year.

Harvester Ants (native fire ants) found in SW; stings painful, but fatalities rare

Imported Fire Ants found in SE and Gulf coast; will spread much further north & west from global warming

Ants bite, and deliver multiple stings in circular pattern; aggressive & swarm - attacks 6 - 60% of people living in an area during each year.

Harvester Ants (native fire ants) found in SW; stings painful, but fatalities rare

Hymenoptera: Formicids (Ants)Hymenoptera:

Formicids (Ants)

Page 17: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Imported Fire Ant RangeImported Fire Ant Range

Tracy JM, Demain JG, Quinn JM et al. The natural history of exposure to theimported fire ant (Solenopsis invicta). J Allergy Clin Immunol 1995; 95:824-828

At Risk: Pacific Northwest, Arizona, Virginia

Page 18: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Sting Risk FactorsSting Risk Factors

Page 19: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Risk Factors for Serious Sting Reactions 1

Risk Factors for Serious Sting Reactions 1

Survey of 494 beekeepers:• 90% stung/year, 55% had >100 stings

• 6.5% had serious reactions

• Risks: having any kind of allergies, especially asthma, food allergies, or multiple kinds of allergies

Survey of 494 beekeepers:• 90% stung/year, 55% had >100 stings

• 6.5% had serious reactions

• Risks: having any kind of allergies, especially asthma, food allergies, or multiple kinds of allergies

Celikel S, Karakaya G, Yurtsever N et al. Bee and bee products allergy in Turkish beekeepers:determination of risk factors for systemic reactions. Allergol Immunopathol (Madr). 2006;34(5):180-4.

Page 20: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Risk Factors for Serious Sting Reactions 2

Risk Factors for Serious Sting Reactions 2

Survey of 1053 beekeepers:• annual stings/person 0-1000, average 58

• 4.4% had serious reactions

• Risks: current allergy symptoms, having allergies, years as beekeeper, stings in spring

Survey of 1053 beekeepers:• annual stings/person 0-1000, average 58

• 4.4% had serious reactions

• Risks: current allergy symptoms, having allergies, years as beekeeper, stings in spring

 Münstedt K, Hellner M, Winter D, et al. Allergy to bee venom in beekeepers in Germany.J Investig Allergol Clin Immunol. 2008;18(2):100-5

Page 21: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Developing Bee Allergy in New Beekeepers

Developing Bee Allergy in New Beekeepers

35 new beekeepers tested for 5 years:

• 29% became venom sensitive

• most within 12 months, all by 18 months

• number of stings and presence of other allergies had no effect on developing sting allergy

35 new beekeepers tested for 5 years:

• 29% became venom sensitive

• most within 12 months, all by 18 months

• number of stings and presence of other allergies had no effect on developing sting allergy

Kalogeromitros D, Makris M, Gregoriou S et al. Pattern of sensitization to honeybeevenom in beekeepers: a 5-year prospective study. Allergy Asthma Proc. 2006;27(5):383-7

Page 22: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Predicting Risk of Serious Reaction in Beekeepers

Predicting Risk of Serious Reaction in Beekeepers

78 beekeepers studied before being stung

Risks are:

• pre-exposure high IgE blood test > 1 ku/L

• allergic nasal, eye, or lung symptoms during hive work

• less than 8 years beekeeping

• prior serious sting reaction

78 beekeepers studied before being stung

Risks are:

• pre-exposure high IgE blood test > 1 ku/L

• allergic nasal, eye, or lung symptoms during hive work

• less than 8 years beekeeping

• prior serious sting reaction

Annila IT, Annila PA, Mörsky P. Risk assessment in determining systemic reactivityto honeybee stings in beekeepers. Ann Allergy Asthma Immunol. 1997;78(5):473-7.

Page 23: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Consecutive Stings increase Anaphylaxis Risk

Consecutive Stings increase Anaphylaxis Risk

120 sting-allergic persons:

• 59% of serious reactions occur when there was a prior sting within 2 months (p=0.0001 - highly significant)

120 sting-allergic persons:

• 59% of serious reactions occur when there was a prior sting within 2 months (p=0.0001 - highly significant)

Pucci S, Antonicelli L, Bilò MB et al. Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy. 1994;49(10):894-6.

Page 24: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Fewer Stings increase Anaphylaxis Risk

Fewer Stings increase Anaphylaxis Risk

176 sting-allergic beekeepers:

• reaction risk is inversely correlated with annual number of stings

176 sting-allergic beekeepers:

• reaction risk is inversely correlated with annual number of stings

Bousquet J, Ménardo JL, Aznar R et al. Clinical and immunologic survey in beekeepers in relation to their sensitization. J Allergy Clin Immunol. 1984;73(3):332-40.

Page 25: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Types of Sting ReactionsTypes of Sting Reactions

• Immediate Allergic– Local, Large Local, Systemic

• Delayed Toxic (Non-Allergic)– Serum sickness, CNS demyelination,

vascular thrombosis, glomerulonephritis, myocarditis, multi-organ failure, and death

– Multiple stings required :

LD50 (honeybee) > 500 stings

• Immediate Allergic– Local, Large Local, Systemic

• Delayed Toxic (Non-Allergic)– Serum sickness, CNS demyelination,

vascular thrombosis, glomerulonephritis, myocarditis, multi-organ failure, and death

– Multiple stings required :

LD50 (honeybee) > 500 stings

Graft DF. Stinging insect hypersensitivity in children.Curr Opin Ped. 1996; 8:597-600

Page 26: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immediate Therapy

for all BeeStings

Immediate Therapy

for all BeeStings

• Rapidly remove all bee venom sacs - envenomation is complete in one minute !

• Use your HIVE TOOL !

• Rapidly remove all bee venom sacs - envenomation is complete in one minute !

• Use your HIVE TOOL ! Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.

Page 27: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Toxic Sting ReactionsToxic Sting Reactions• Honeybees (especially Africanized) or Wasps

(yellowjackets and hornets)• Without treatment, > 20-200 wasp stings

or > 150-1000 bee stings can be fatal• Symptoms may not appear for hours to

several days• Go to the hospital immediately for any mass

sting (call 911 !!!)

• Honeybees (especially Africanized) or Wasps (yellowjackets and hornets)

• Without treatment, > 20-200 wasp stings or > 150-1000 bee stings can be fatal

• Symptoms may not appear for hours to several days

• Go to the hospital immediately for any mass sting (call 911 !!!)

Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med. 1999;170(4):223-7.

Page 28: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Allergic Reactionsto Insect Stings

Allergic Reactionsto Insect Stings

1. Local: pain, redness at site

2. Large Local: swelling of extremity

3. Systemic: generalized, involves any symptoms at a remote site from the sting. These may quickly be life threatening.

1. Local: pain, redness at site

2. Large Local: swelling of extremity

3. Systemic: generalized, involves any symptoms at a remote site from the sting. These may quickly be life threatening.

Page 29: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immediate Therapyfor Stings

Immediate Therapyfor Stings

• Local reaction: ice, antihistamine• Local reaction: ice, antihistamineSchumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.

Page 30: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immediate Therapyfor Stings

Immediate Therapyfor Stings

• Large Local reaction: ice, antihistamine, prescription prednisone

• Large Local reaction: ice, antihistamine, prescription prednisone

Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.

Page 31: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immediate Therapyfor Stings

Immediate Therapyfor Stings

• Systemic reactions: give epinephrine & treat for anaphylaxis. Call 911 !!!

• Systemic reactions: give epinephrine & treat for anaphylaxis. Call 911 !!!

Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. 1994;93(5):831-5.

Page 32: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Systemic ReactionsSystemic Reactions

• Treat immediately !

• If you think of epinephrine, USE IT !

• Epinephrine 1:1000 (0.01ml/kg) = 0.3 ml adult, 0.15 ml child. Inject into muscle !

• Be ready to Re-Treat. Epinephrine may only last 5-10 minutes.

• Treat immediately !

• If you think of epinephrine, USE IT !

• Epinephrine 1:1000 (0.01ml/kg) = 0.3 ml adult, 0.15 ml child. Inject into muscle !

• Be ready to Re-Treat. Epinephrine may only last 5-10 minutes.

Page 33: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• Epinephrine is required more than once in 35% of anaphylaxis cases

• Most insurance companies cover dual packs of epinephrine injectors. Buy them !

• Epinephrine is required more than once in 35% of anaphylaxis cases

• Most insurance companies cover dual packs of epinephrine injectors. Buy them !Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine administration for anaphylaxis: how many doses are needed? Allergy Asthma Proc. 1999;20(6):383-6.

Systemic ReactionsSystemic Reactions

Page 34: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Epinephrine Use

Epinephrine Use

• Caution after

removing safety cap

- don’t inject hand• Swing hard• Inject right

through your clothes• Hold against leg &

count slowly to 10

Page 35: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

After Giving EpinephrineAfter Giving Epinephrine

• CALL 911 • Keep giving Epinephrine, as often

as needed to control symptoms• If patient has asthma, USE THEIR

INHALERS• If available, give oral

Antihistamine and Oxygen

• CALL 911 • Keep giving Epinephrine, as often

as needed to control symptoms• If patient has asthma, USE THEIR

INHALERS• If available, give oral

Antihistamine and Oxygen

Page 36: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Facts to RememberFacts to Remember

Clinical History - helps with treatment

Important to Identify:

• what kind of insect

• type of reaction

• severity of reaction

• ? progression of this reaction over time

• ? worse compared to last sting

Clinical History - helps with treatment

Important to Identify:

• what kind of insect

• type of reaction

• severity of reaction

• ? progression of this reaction over time

• ? worse compared to last sting

Page 37: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• Winged / flying eliminates Fire Ants

• Stinger left in skin : Honeybee

• Nest location : ground favors Yellow

Jacket (bumble bee less common)

• Large size: favors Hornet

• Narrow waist: not a bee or bumblebee

• Winged / flying eliminates Fire Ants

• Stinger left in skin : Honeybee

• Nest location : ground favors Yellow

Jacket (bumble bee less common)

• Large size: favors Hornet

• Narrow waist: not a bee or bumblebee

What Insect Was it ?What Insect Was it ?

Page 38: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

WhichInsects to Test 1

WhichInsects to Test 1

• About 90% of stings are from Wasps

• Always test Yellow Jacket (most aggressive, most likely to sting)

• If Wasp or Hornet is likely, test all local species

• If Africanized bees are local, test Honeybee

• About 90% of stings are from Wasps

• Always test Yellow Jacket (most aggressive, most likely to sting)

• If Wasp or Hornet is likely, test all local species

• If Africanized bees are local, test Honeybee

Pérez-Pimiento AJ, González-Sánchez LA, Prieto-Lastra L, et al. Anaphylaxis to hymenoptera sting: study of 113 patients. Med Clin (Barc). 2005;125(11):417-20.

Page 39: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Which Insects to Test 2Which Insects to Test 2

• If stinger found, test Honeybee

• When unsure, test Honeybee & Yellow Jacket

• If stung by Bumblebee (large bee), test for Honeybee and Bumblebee

• If poor history, test all local species

• If stinger found, test Honeybee

• When unsure, test Honeybee & Yellow Jacket

• If stung by Bumblebee (large bee), test for Honeybee and Bumblebee

• If poor history, test all local species

Page 40: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Why to do In Vitro (Blood) Tests Why to do In Vitro (Blood) Tests • IgE:

– To identify culprit insect ( may be falsely negative in 15-20%)

– To determine degree of sensitivity – To differentiate toxic and allergic Rxn– For Safety, prior to Skin Testing

• IgG :– To check progress of desensitization

• IgE: – To identify culprit insect ( may be falsely

negative in 15-20%)– To determine degree of sensitivity – To differentiate toxic and allergic Rxn– For Safety, prior to Skin Testing

• IgG :– To check progress of desensitization

Reisman RE. Stinging Insect Allergy. Med Clin NA 1992; 76:883-894

Page 41: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• If blood test is negative, and suspicion of

allergic reaction is high

• if immunotherapy is needed, skin test must

precede beginning treatment

• If blood test is negative, and suspicion of

allergic reaction is high

• if immunotherapy is needed, skin test must

precede beginning treatment

Why to do Skin TestsWhy to do Skin Tests

Page 42: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Bee-Venom Allergywithout positive TestsBee-Venom Allergy

without positive Tests

• In very rare patients with classic bee sting anaphylaxis history, blood tests and skin tests may both be negative.

• If an in-hospital sting challenge is positive, immunotherapy is indicated.

• In very rare patients with classic bee sting anaphylaxis history, blood tests and skin tests may both be negative.

• If an in-hospital sting challenge is positive, immunotherapy is indicated.

Zidarn M, Kosnik M, Drinovec I. Anaphylaxis after Hymenoptera sting without detectable

specific IgE. Acta Dermatovenerol Alp Panonica Adriat. 2007 ;16(1):31-3.

Page 43: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Insect Avoidance– Caution during outdoor activities

• Look for nests on ground, roofs

– Extra care in Picnic areas• Orchards, trash containers, soda cans, fruit

– Wear shoes, long sleeves, pants, gloves– Avoid fragrances, bright colors– Use protective suit, veil, & gloves when

working with bees

Insect Avoidance– Caution during outdoor activities

• Look for nests on ground, roofs

– Extra care in Picnic areas• Orchards, trash containers, soda cans, fruit

– Wear shoes, long sleeves, pants, gloves– Avoid fragrances, bright colors– Use protective suit, veil, & gloves when

working with bees

Management of ProvenStinging Insect AllergyManagement of ProvenStinging Insect Allergy

Page 44: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• Epinephrine kits– Kits must be with you to be useful

• epinephrine stability is poor with oxygen, light, & heat ( replace kits as needed )

– Practice epinephrine use– Always call 911 after epinephrine

• Antihistamines & corticosteroids are OK to use AFTER epinephrine

• Epinephrine kits– Kits must be with you to be useful

• epinephrine stability is poor with oxygen, light, & heat ( replace kits as needed )

– Practice epinephrine use– Always call 911 after epinephrine

• Antihistamines & corticosteroids are OK to use AFTER epinephrine

Management ofStinging Insect Allergy

Management ofStinging Insect Allergy

Page 45: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Venom Immunotherapy (Allergy Shots) - should be considered in all persons who:

• have a positive history of one or more Systemic Reactions to stings

• have a positive diagnostic test

• are likely to be re-stung

Venom Immunotherapy (Allergy Shots) - should be considered in all persons who:

• have a positive history of one or more Systemic Reactions to stings

• have a positive diagnostic test

• are likely to be re-stung

Management ofStinging Insect Allergy

Management ofStinging Insect Allergy

Page 46: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Who Needs Immunotherapy ?Who Needs Immunotherapy ?

Only 25 - 50% of patients repeat Systemic Reactions when re-stung

• risk increases with repeat stings, especially if close together in time

• higher risk for occupational exposure

• higher risk for asthmatics

• highest risk if Circulatory Shock occurs

• clinical judgement required

Only 25 - 50% of patients repeat Systemic Reactions when re-stung

• risk increases with repeat stings, especially if close together in time

• higher risk for occupational exposure

• higher risk for asthmatics

• highest risk if Circulatory Shock occurs

• clinical judgement required

Page 47: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

• Treatment effectiveness is 97% (Wasps) or 80% (Honeybees)

• About 20% have mild reactions due to treatment, usually early in therapy

• Rare patients (0.7 %) require epinephrine during therapy

• Treatment effectiveness is 97% (Wasps) or 80% (Honeybees)

• About 20% have mild reactions due to treatment, usually early in therapy

• Rare patients (0.7 %) require epinephrine during therapy

Immunotherapy ResultsImmunotherapy Results

1. Mosbech H, Muller U. Side-effects of insect venom immunotherapy:results from an EAACI multicenter study. Allergy 2000; 55:1005-10102. Muller UR. Duration of venom immunotherapy. J Allergy Clin Immunol.1997; 95:271-272

Page 48: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immunotherapy ResultsImmunotherapy Results

146 sting immunotherapy cases, at 6.5 years after beginning treatment.

• High Risk of re-sting (41%)

• Most had improved quality of life (90% had less fear and fewer changes in lifestyle on immunotherapy)

146 sting immunotherapy cases, at 6.5 years after beginning treatment.

• High Risk of re-sting (41%)

• Most had improved quality of life (90% had less fear and fewer changes in lifestyle on immunotherapy)

Roesch A, Boerzsoenyi J, Babilas P. et al. Outcome survey of insect venom allergic

patients with venom immunotherapy in a rural population.

J Dtsch Dermatol Ges. 2008;6(4):292-7.

Page 49: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Immunotherapy ResultsImmunotherapy Results181 sting immunotherapy cases, 1 - 27 years after at least 3 years of treatment.

• High Risk of re-sting (55%)

• Most had only local reactions (92%)

• Systemic reactions (8% ) were milder than before treatment

181 sting immunotherapy cases, 1 - 27 years after at least 3 years of treatment.

• High Risk of re-sting (55%)

• Most had only local reactions (92%)

• Systemic reactions (8% ) were milder than before treatment

Hafner T, DuBuske L, Kosnik M. Long-term efficacy of venom immunotherapy.

Ann Allergy Asthma Immunol. 2008 100(2):162-5.

Page 50: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Benefits of Immunotherapyfor Beekeepers

Benefits of Immunotherapyfor Beekeepers

459 bee-allergic patients:• 14% were beekeepers, and 10% were beekeeper’s family members• beekeepers vs non-beekeepers: there was no difference in results of immunotherapy• beekeepers had less problems with IT• most beekeepers continued beekeeping with immunotherapy protection

459 bee-allergic patients:• 14% were beekeepers, and 10% were beekeeper’s family members• beekeepers vs non-beekeepers: there was no difference in results of immunotherapy• beekeepers had less problems with IT• most beekeepers continued beekeeping with immunotherapy protection

Eich-Wanger C, Müller UR. Bee sting allergy in beekeepers.Clin Exp Allergy. 1998;28(10):1292-8.

Page 51: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Repeated Stings may increase Reaction Severity

Repeated Stings may increase Reaction Severity

40 sting allergy immunotherapy cases, after at least 3 years of treatment, were then re-stung more than once.

• 83% remained desensitized

• 17% had progressively more severe reactions with each subsequent sting (like people never treated with immunotherapy)

40 sting allergy immunotherapy cases, after at least 3 years of treatment, were then re-stung more than once.

• 83% remained desensitized

• 17% had progressively more severe reactions with each subsequent sting (like people never treated with immunotherapy)

Hafner T, DuBuske L, Kosnik M. Long-term efficacy of venom immunotherapy.

Ann Allergy Asthma Immunol. 2008 100(2):162-5.

Page 52: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Lab Check on ImmunityLab Check on ImmunityIgG and IgE can be measured in blood.

• If protective immunity is occurring:

– IgE should decrease

– IgG should increase

• Higher venom doses can be used if standard doses do not work

IgG and IgE can be measured in blood.

• If protective immunity is occurring:

– IgE should decrease

– IgG should increase

• Higher venom doses can be used if standard doses do not work

1. Valentine MD, Lichtenstein LM. Anaphylaxis and stinging insect hyper-sensitivity. JAMA 1987; 258:2881-28852. Bosquet J, Muller UR, Drebord S, et al. Immunotherapy with Hymenoptera venoms. Allergy 1987; 42:401-413

Page 53: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Difficulty with ImmunizationDifficulty with Immunization

• In rare patients, it is impossible to

increase the venom dose high enough

to produce good immunity, without

triggering unacceptable reactions

• Most people with this problem can

now be helped with anti-IgE

• In rare patients, it is impossible to

increase the venom dose high enough

to produce good immunity, without

triggering unacceptable reactions

• Most people with this problem can

now be helped with anti-IgE

Page 54: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Anti-IgE and ImmunotherapyAnti-IgE and Immunotherapy

Where immunotherapy reactions prevented administering adequate venom doses, adding anti-IgE (omalizumab, Xolair) resulted in success in 7 reported cases

Where immunotherapy reactions prevented administering adequate venom doses, adding anti-IgE (omalizumab, Xolair) resulted in success in 7 reported cases

Galera C, Soohun N, Zankar N.et al. Severe anaphylaxis to bee venom immunotherapy:efficacy of pretreatment and concurrent treatment with omalizumab. J Investig Allergol Clin Immunol. 2009;19(3):225-9..

Page 55: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

When to Stop Bee ImmunotherapyWhen to Stop Bee Immunotherapy

• After 5 years, before stopping maintenance injections, measure blood IgE and IgG

– IgE should drop to 0

– IgG should be > 5 g / ml

• How likely is this person to be restung ?

• How severe was the last sting reaction ?

• Are there any treatment side effects ?

• Weigh the pros and cons carefully

• After 5 years, before stopping maintenance injections, measure blood IgE and IgG

– IgE should drop to 0

– IgG should be > 5 g / ml

• How likely is this person to be restung ?

• How severe was the last sting reaction ?

• Are there any treatment side effects ?

• Weigh the pros and cons carefully

Page 56: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

SummarySummary• Avoidance techniques should always

be employed

• Emergency epinephrine should always be with you

• Accurate diagnosis is critical

• Immunotherapy is highly effective, but treatment failures still can occur

• Avoidance techniques should always be employed

• Emergency epinephrine should always be with you

• Accurate diagnosis is critical

• Immunotherapy is highly effective, but treatment failures still can occur

Page 57: Stinging Insect Allergy Barnstable County Beekeepers Association April 12, 2011 Bruce R. Gordon, MD, FACS, FAAOA Harvard Clinical Instructor President,

Happy, Safe, Beekeeping !