The article by Sheikih and Walker(1) on the management of recent allergic reaction to an insect sting contains several puzzling statements.
First, the statement that “Reactions to further stings are unpredictable” is misleading. Large prospective studies, which also included adults confirmed that future reactions in the same patient usually follow the same pattern.(2,3) The chance of severe systemic reaction(SR) to a future sting in adults with a history of severe anaphylaxis is 60% to 70% but in those with mild SR only 20%.(4,5) The risk of SR in patients with a history of large local reactions is no more than 5% to 10%.(6,7) These data support the current guidelines to focus the provision of adrenaline auto-injectors and venom immunotherapy on people with a history of severe SR.(8)
Second , the notion that “venom allergy is unrelated to atopy” is based on several flawed studies which failed to take into account differences in the degree of exposure (patients with anaphylaxis having higher degree of exposure then control group) causing underestimation of the association. Although sting allergy frequently affects non-atopic subjects, studies in beekeepers show that frequency of SR is higher in atopic individuals (up to 48%), who are also predisposed to more severe reactions. (9,10) Other studies have shown that sensitization to stings correlate positively with atopy.(11-13)
Finally, the authors overlooked that 30% to 50% of all patients with stinging-insect allergy have double-positive CAP-RAST results to honeybee and wasp venom.(14) Although true double-sensitization may account for these results, recent data suggest that cross-reactivity through carbohydrate epitopes is a major cause for this multiple IgE reactivity.(15) FEIA inhibition test may be helpful in discriminating between truly double-sensitized patients who may require immunotherapy with 2 venoms and patients with cross-reacting IgE, for whom restriction of immunotherapy to one venom is beneficial and cost- effective.(16)
1. Sheikh A, Walker S. Anaphylaxis. BMJ 2005;331:330.
2. van der Linden PW, Struyvenberg A, Kraaijenhagen RJ, Hack CE, van der Zwan JK. Anaphylactic shock after insect-sting challenge in 138 persons with a previous insect-sting reaction. Ann Intern Med 1993;118:161 -8.
3. Brown SG, Franks RW, Baldo BA, Heddle RJ. Prevalence, severity, and natural history of jack jumper ant venom allergy in Tasmania. J Allergy Clin Immunol 2003;111:187-192.
4. Hunt KJ, Valentine MD, Sobotka AK, Benton AW, Amodio FJ, Lichtenstein LM. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978;299:157-61.
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6. Mauriello PM, Barde SH, Georgitis JW, Reisman RE. Natural history of large local reactions from stinging insects. J Allergy Clin Immunol 1984;74:494-8.
7. Graft DF, Schuberth KC, Kagey-Sobotka A, Kwiterovich KA, Niv Y, Lichtenstein LM, et al. A prospective study of the natural history of large local reactions after Hymenoptera stings in children. J Pediatr 1984;104:664-8.
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9. Annila IT, Karjalainen ES, Annila PA, Kuusisto PA. Bee and wasp sting reactions in current beekeepers. Ann Allergy Asthma Immunol 1996;77:423-7.
10. Bousquet J, Coulomb Y, Robinet-Levy M, Michel FB. Clinical and immunological surveys in bee keepers. Clin Allergy 1982;12:331-42.
11. Miyachi S, Lessof MH, Kemeny DM, Green LA. Comparison of the atopic background between allergic and non-allergic beekeepers. Int Arch Allergy Appl Immunol 1979;58:160-6.
12. Schafer T, Przybilla B. IgE antibodies to Hymenoptera venoms in the serum are common in the general population and are related to indications of atopy. Allergy 1996;51:372-7.
13. Novembre E, Cianferoni A, Bernardini R, Veltroni M, Ingargiola A, Lombardi E, et al. Epidemiology of insect venom sensitivity in children and its correlation to clinical and atopic features. Clin Exp Allergy 1998;28:834-8.
14. Egner W, Ward C, Brown DL, Ewan PW. The frequency and clinical significance of specific IgE to both wasp (Vespula) and honey-bee (Apis) venoms in the same patient. Clin Exp Allergy 1998;28:26-34.
15. Hemmer W, Focke M, Kolarich D, Wilson IB, Altmann F, Wohrl S, et al. Antibody binding to venom carbohydrates is a frequent cause for double positivity to honeybee and yellow jacket venom in patients with stinging-insect allergy. J Allergy Clin Immunol 2001;108:1045-52.
16. Straumann F, Bucher C, Wuthrich B. Double sensitization to honeybee and wasp venom: immunotherapy with one or with both venoms? Value of FEIA inhibition for the identification of the cross-reacting ige antibodies in double-sensitized patients to honeybee and wasp venom. Int Arch Allergy Immunol 2000;123:268-74.
About the author:
Dr. Michal R. Pijak is a consultant in rheumatology, allergy and clinical immunology at the University Hospital in Bratislava, Slovakia
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