Diagnosis and management of hymenoptera sting <br />SadudeeBoonmee,MD<br />
Outline<br />Epidermiology of hymenoptera stings<br />Clinical presentation <br />Diagnosis <br />Investigation <br />Trea...
Most of them are glycoproteins of 10–50 kDa containing 100–400 amino acid<br />	- vasoactive amines (e.g. histamine, dopam...
Venom protein per sting<br />50-140 mcg<br />10–31 mcg<br />1.7–3.1 mcg<br />2.4-5.0 mcg<br />4.2 to 17 mcg<br />Diagnosis...
Apis species in Thailand <br />Dwarf honey bee or Red dwarf honey bee ผึ้งมิ้ม มีขนาดลำตัวและรังขนาดเล็กชั้นเดียว ท้องปล้อ...
Apis species in Thailand <br />Asiatic honey bee or Eastern honey bee ผึ้งโพรงเอเชีย มีเขตแพร่กระจายในอัฟกานิสถาน ปากีสถาน...
Apis species in Thailand<br />Giant bee ผึ้งหลวง มีขนาดลำตัว และรังใหญ่ที่สุด สร้างรังเป็นรูปครึ่งวงกลมชั้นเดียว ไม่มีที่ป...
VespidSubfamily Vespinae<br />
Black-bellied hornet<br />Vespabasalis <br />ต่อเมืองเหนือ หรือต่อหัวเสือท้องดำ<br />Lesser nocturnal hornet Provespaanoma...
VespidSubfamily Polistinae<br />
แตนท้องยาวแถบเหลือง <br />Slender banded paper <br />แตนใบไม้เล็ก parapolybiavaria<br />รังแตน<br />แตนวงเหลือง<br />ropal...
Ant <br />VS<br />
เตือน'อิวิคต้า'มดคันไฟมหาภัยกัดต่อยถึงตายมดคันไฟที่รู้จักกันในชื่อว่า อินวิคตา (Invicta) มีชื่อภาษาอังกฤษว่า Red imported ...
Cross Reactivity<br />
Double or even multiple positive<br />	- true double sensitization<br />	- cross-reactive <br />Cross-Reactivity<br />Diag...
Cross-reactivity within the Apidae family<br />	- major allergens honeybees worldwide are very similar structure of the ma...
Cross-reactivity within vespid venoms<br />Cross-reactivity among vespids is strong  similarities of venom composition (i...
Cross-reactivity between venoms of Apidae and Vespidae<br />	- hyaluronidase50% sequence identity between honeybee and ves...
Double positive in vitro test can discreminated by skin test  positive result more seen only to the venom which truly sen...
Depending on the country’s climate<br />Prevalence <br />	- 56 – 94% are stung by insect in hymenoptera family at least on...
Sensitization 9.3 – 27.8%  ( positive skin test or detection of specific IgE in patients with no previous case history or ...
Large local reaction (LLR)  : 2.4-26.4%<br />	- In children is 19% <br />	- 38% in beekeepers<br />Systemic reaction <br /...
1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
Anaphylactic shock was reported in 0.6–42.8% <br />Fatal rate 0.03-0.48 per 100,000 inhabitants per year ( in USA and Euro...
Epidemiology in Thailand<br />Thammasat : Occurrencerateofanaphylaxisin ED;food 40%,drugs 36%,insects5%<br />Poachanukoon ...
ANAPHYLAXIS IN ADMITED PATIENT A 5 YEARS EXPERIENCE IN CHONBURI HOSPITAL <br />The common causes of anaphylaxis was food (...
Clinical Presentation<br />
Local reaction<br />Most insect stings  local reactions<br />	- Redness<br />	- Swelling<br />	- Itching and pain<br />La...
Systemic reaction <br />Manifestations not contiguous with the site of the sting  mild to lifethreatening.<br />	- cutane...
Non-allergic manifestations<br />No evidence that these are IgE mediated although the underlying mechanisms are not known....
Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
Rare : under-recognized.<br />Insect stings  one quarter of all anaphylactic deaths in the United Kingdom each year.<br /...
1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
Risk factor of Hymenoptera Venom allergy <br />
Risk factor of Hymenoptera Venom allergy <br />The frequency of a systemic reaction is affected by the following factors<b...
<ul><li>Sensitization to venom : Ig E sensitization a risk</li></ul>	factor for subsequent SRs<br /><ul><li>Severity of th...
<ul><li>Insect : Bee venom > vespid  for systemic reaction on next sting.
Bee keeper : Frequently stung                  </li></ul>	< 15-25 sting per year  high risk of SR <br />	> 200 sting per ...
Elevated Baseline tryptase and mastocytosis</li></ul>อธิบายแต่ละอัน<br />Diagnosis and management of hymenoptera venom all...
Natural history of insect sting allergy: Relationship of severity of symptoms of initial sting anaphylaxis to re-sting rea...
Natural history of insect sting allergy: Relationship of severity of symptoms of initial sting anaphylaxis to re-sting rea...
Diagnosis<br />
Investigations for hymenoptera venom allergy<br />Detailed history  <br /><ul><li>Date of sting reactions
Severity of symptoms
Interval between sting and the onset of symptom
Progression of reaction
Emergency treatment
Sting site
Retained or removed stinger
Environment and activities before sting
Risk factors of severe reaction
Risk factors for repeated re-stings
Tolerated stings after the first systemic reactions</li></ul>Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 133...
Demonstration of venom-specific immunoglobulin E <br />Skin test <br />	- immediately available <br />	- greater discrimin...
SPT with standardized venom extracts <br />	(0.01–100 mcg/mL) with both bee and wasp venoms<br />If SPT negative but stron...
2. Serum-specific IgE<br /><ul><li>level of ≥ 0.35 kU/L   positive
SPT and serum specific IgE not correlate with clinical, must be interpreted  with clinical history
Double positivity (wasp and bee venom)  30%</li></ul>Investigations for hymenoptera venom allergy<br />Diagnosis and mana...
Baseline tryptase :<br />-patient with anaphylaxis to hymenoptera sting have an elevated ( ≥11.4 mg/L) baseline tryptase ...
	- Patients with     baseline tryptase with or without systemic mastocytosis develop more severe(cardiovascular reactions)...
Serum total specific IgE<br />	nonspecific <br />	total serum IgE of > 250 kU/L is more likely to indicate asymptomatic se...
Sting challenge test <br />Untreated patients with or without a history of anaphylactic sting reactions, to identify who n...
Management<br />
1.Treatment of acute reaction <br />
Provision of management plan<br />	- Treatment plan :antihistamine used, self-injectable adrenaline, supine posture with l...
Patients who have had a systemic reaction from an insect sting and have venom-specific IgE antibodies<br />The goals of VI...
Theodore M.Freeman. N Engl J Med2004;351:1978-84.<br />
The risk of non treatment includes the chance of future<br />stings causing either mild reactions or life-threatening<br /...
Prospective studies have shown that patients 16 years of age and younger who have experienced cutaneous systemic reactions...
Between 1978 and 1985,diagnosed allergic reaction to insect stings in 1033 children, of whom 356 received venom immunother...
N Engl J Med 2004;351:668-74.<br />
N Engl J Med 2004;351:668-74.<br />
VIT is generally not necessary for patients 16 years of age and younger who have experienced only cutaneous systemic react...
Adults who have experienced only cutaneous manifestations to an insect sting are generally considered candidates for VIT, ...
The New England Journal of Medicine ;1994<br />
	- VIT usually not indicated for sting-induced cutaneous SRs but may be considered in<br /> raised baseline tryptase<br /...
VIT is generally not necessary in patients who have experienced only large local reactions to stings but might be consider...
Venom immunotherapy reduces large local reactions to insect stings(J Allergy ClinImmunol 2009;123:1371-5.)<br />
Selection of venom to be used in immunotherapy<br />Honeybeeandbumblebeevenomsshowmarkedcross-reactivity<br />Venomimmunot...
Selection of venom to be used in immunotherapy<br />Cross-reactivityexistsbetweenthemajorvenomcomponentsofseveralvespids, ...
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Diagnosis and management of hymenoptera sting

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Diagnosis and management of hymenoptera sting

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Diagnosis and management of hymenoptera sting

  1. 1. Diagnosis and management of hymenoptera sting <br />SadudeeBoonmee,MD<br />
  2. 2. Outline<br />Epidermiology of hymenoptera stings<br />Clinical presentation <br />Diagnosis <br />Investigation <br />Treatment <br />
  3. 3.
  4. 4. Most of them are glycoproteins of 10–50 kDa containing 100–400 amino acid<br /> - vasoactive amines (e.g. histamine, dopamine, norepinephrine)<br /> - acetylcholine<br /> - kinin<br />Venom allergen <br />Burning pain and itching <br />
  5. 5. Venom protein per sting<br />50-140 mcg<br />10–31 mcg<br />1.7–3.1 mcg<br />2.4-5.0 mcg<br />4.2 to 17 mcg<br />Diagnosis of Hymenoptera venom allergy Allergy 2005: 60: 1339–1349<br />
  6. 6. Apis species in Thailand <br />Dwarf honey bee or Red dwarf honey bee ผึ้งมิ้ม มีขนาดลำตัวและรังขนาดเล็กชั้นเดียว ท้องปล้องแรกสีส้ม ปล้องต่อไปจะเป็นสีดำสลับสีเหลืองอ่อน มักสร้างรังอยู่บนกิ่งไม้ขนาดเล็ก และมีกิ่งไม้ปกปิด เพื่อป้องกันศัตรูพบเห็น ผึ้งมิ้มพบทั่วไปในประเทศไทย และทุกประเทศในเอเชียตะวันออกเฉียงใต้ขึ้นไปจนถึงจีนตอนใต้<br />www.maleang.com<br />
  7. 7. Apis species in Thailand <br />Asiatic honey bee or Eastern honey bee ผึ้งโพรงเอเชีย มีเขตแพร่กระจายในอัฟกานิสถาน ปากีสถาน ทางเหนือของอินเดีย บังคลาเทศ จีน เวียดนาม ญี่ปุ่น ปาปัวนิวกินี รวมทั้งไทย<br />Indian honey bee ผึ้งโพรงอินเดีย มีเขตแพร่กระจายทางใต้ของอินเดีย ศรีลังกา บังคลาเทศ พม่า ไทย มาเลเซีย อินโดนีเซีย และฟิลลิปปินส์ ผึ้งโพรงทั้งสองชนิดย่อยมีลักษณะคล้ายกันมาก มีขนาดลำตัวใหญ่กว่าผึ้งมิ้ม แต่เล็กกว่าผึ้งหลวง ลำตัวสีน้ำตาลปนดำ ช่วงท้องแต่ละปล้องมีแถบขาวหรือเหลืองอ่อนสลับดำเห็น ชัดเจนมาก มักสร้างรังเป็นชั้น ๆ ซ้อนกันในโพรงต้นไม้ หรือในอาคารบ้านเรือนที่มิดชิด ผึ้งโพรงพบทั่วไปในประเทศไทยและทุกประเทศ ตั้งแต่เอเชียใต้ลงมาจนถึง เอเชียตะวันออกเฉียงใต้ ผึ้งโพรงไทยสามารถนำมาเลี้ยง ในหีบหรือกล่องไม้ได้ และทำรายได้ให้แก่เกษตรกรผู้เลี้ยงผึ้งไม่น้อย<br />www.maleang.com<br />
  8. 8. Apis species in Thailand<br />Giant bee ผึ้งหลวง มีขนาดลำตัว และรังใหญ่ที่สุด สร้างรังเป็นรูปครึ่งวงกลมชั้นเดียว ไม่มีที่ปกปิด มักสร้างรังบนต้นไม้สูง ๆ ตามชายคาบ้านเรือน และตามหน้าผาสูง ช่วงท้องจะมีสีเหลืองและสีดำ ลำตัวด้านหลังมีสีน้ำตาลอ่อนอมเหลืองจนถึงสีน้ำตาลแก่ ด้านท้องสีดำ ลักษณะนิสัยดุและต่อยปวดกว่าผึ้งทุกชนิด ในเดือนเมษายนจะให้น้ำผึ้งได้ดีที่สุด เรียกว่า น้ำผึ้งเดือนห้า ผึ้งหลวงพบทั่วไปในประเทศไทย และทุกประเทศของทวีปเอเชียตะวันออกเฉียงใต้ขึ้นไปจนถึงจีนตอนใต้ พม่า ศรีลังกา เนปาล และอินเดีย<br />European honey bee or Western honey bee ผึ้งโพรงฝรั่ง หรือ ผึ้งยุโรป มีขนาดใหญ่กว่าผึ้งโพรงไทย แต่เล็กกว่าผึ้งหลวง นิสัยไม่ดุเหมือนผึ้งหลวง และไม่ทิ้งรังง่ายเหมือนผึ้งโพรงไทย เป็นผึ้งที่นำเข้ามาจากต่างประเทศ ปัจจุบันนิยมเลี้ยงกันมากในจังหวัดภาคเหนือคือ พิษณุโลก อุตรดิตถ์ แพร่ น่าน ลำปาง ลำพูน เชียงใหม่ และเชียงราย ผึ้งโพรงฝรั่งมีประชากรผึ้งงานในรังมากกว่าผึ้งโพรงไทยประมาณสองเท่าคือ ผึ่งโพรงฝรั่งมีประมาณ40,000-50,000 ตัวต่อรัง จึงมีบทบาทมากในการผลิตน้ำผึ้งเพื่ออุตสาหกรรม<br />www.maleang.com<br />
  9. 9. VespidSubfamily Vespinae<br />
  10. 10. Black-bellied hornet<br />Vespabasalis <br />ต่อเมืองเหนือ หรือต่อหัวเสือท้องดำ<br />Lesser nocturnal hornet Provespaanomala  ต่อนอนวันเล็ก<br />รังต่อหัวเสือบ้าน<br />Tropical hornet<br />Vespatropicana<br />ต่อหลุม<br />Asian giant hornet<br />Vespamandarinia <br />ต่อหัวเสือยักษ์<br /> Lesser banded hornet<br />Vespaaffinis  <br /> ต่อหัวเสือบ้าน<br />
  11. 11. VespidSubfamily Polistinae<br />
  12. 12. แตนท้องยาวแถบเหลือง <br />Slender banded paper <br />แตนใบไม้เล็ก parapolybiavaria<br />รังแตน<br />แตนวงเหลือง<br />ropalidia<br />marginata<br />แตนวงขาว Ropalidia sp. <br />
  13. 13. Ant <br />VS<br />
  14. 14. เตือน'อิวิคต้า'มดคันไฟมหาภัยกัดต่อยถึงตายมดคันไฟที่รู้จักกันในชื่อว่า อินวิคตา (Invicta) มีชื่อภาษาอังกฤษว่า Red imported Fire Ant หรือ RIFA ชื่อวิทยาศาสตร์เรียกกันว่า SolenopsisInvictaจัดเป็นแมลงที่อยู่ในอันดับ Hymenoptera โดยจัดอยู่ในสกุลของมด ที่มีชื่อเรียกว่า สกุล Formicidaeถิ่นกำเนิดของมดคันไฟชนิดนี้อยู่ไกลจากประเทศไทยมากมายนัก โดยมีถิ่นกำเนิดไกลถึงแถบทวีปอเมริกาใต้ ต่อมาได้แพร่กระจายไปเกือบทั่วโลกและเริ่มขยายพันธุ์เข้ามาในเอเชียเมื่อสองถึงสามปีนี้พบได้ในไต้หวันและฮ่องกง และคาดว่าจะเข้ามาสู่ประเทศไทยในไม่ช้านี้ มดคันไฟอิวิคต้าสามารถปรับตัวและขยายพันธุ์ได้อย่างรวดเร็ว จนประเทศที่มีการระบาดของมดคันไฟอิวิคต้าต้องมีการจัดตั้งศูนย์เตือนภัยขึ้นมา เพื่อยับยั้งการขยายพันธุ์ บรรเทาความเดือดร้อนของผู้ที่โดนต่อย และเกษตรกรที่ได้รับผลกระทบจากการกัดกินพืชผักต่าง ๆ มดคันไฟอิวิคต้าชอบสร้างถิ่นอาศัยบริเวณที่มีน้ำไหลเวียน มีปริมาณ น้ำฝนมากกว่า 550 มิลลิเมตรต่อปี อาทิ พื้นที่การเกษตร สวนป่า ทุ่งหญ้า ฝั่งแม่น้ำลำคลอง ชายฝั่งทะเล ทะเลทราย และสนามกอล์ฟ มักสร้างถิ่นอาศัยแบบเป็นรังหรือเป็นจอมโดยใช้มูลดิน ซึ่งจะมีเส้นผ่าศูนย์กลางมากกว่า 1 เมตร ความสูงประมาณ 4-24 นิ้ว ส่วนมดคันไฟที่มีอยู่ในไทยจะสร้างรังเรียบ ๆ กับพื้น ไม่มีจอม และมีจำนวนประชากรมากถึง 500,000 ตัวต่อรัง ขณะที่มดคันไฟธรรมดาจะมีเพียง 10,000 ตัวต่อรัง<br />เดลินิวส์ 29-7-52<br />
  15. 15. Cross Reactivity<br />
  16. 16. Double or even multiple positive<br /> - true double sensitization<br /> - cross-reactive <br />Cross-Reactivity<br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  17. 17. Cross-reactivity within the Apidae family<br /> - major allergens honeybees worldwide are very similar structure of the major allergen phospholipase A2 highly identical.<br /> - Bumblebee PLA2 only 53% identical to honeybee  immunologic cross-reactivity does exist.<br />Cross-Reactivity <br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  18. 18. Cross-reactivity within vespid venoms<br />Cross-reactivity among vespids is strong  similarities of venom composition (identities up to 95%) <br /> - cross-reactivity within vespinae (Vespula, Vespa, and Dolichovespula) venoms<br /> - Cross-reactivity of the Vespinae with paperwasps (Polistes) is lower than cross-reactivity within the Vespinae<br />Cross-Reactivity<br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  19. 19. Cross-reactivity between venoms of Apidae and Vespidae<br /> - hyaluronidase50% sequence identity between honeybee and vespid venoms  major cross reactive component <br />Cross-Reactivity<br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  20. 20. Double positive in vitro test can discreminated by skin test  positive result more seen only to the venom which truly sensitized.<br />Species-specific recombinant major allergens<br /> - Api m 1( bee venom )<br /> - Ves v5 ( vespula ) <br /> Identifying true sensitization when dual positive.<br />Cross-Reactivity <br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  21. 21. Depending on the country’s climate<br />Prevalence <br /> - 56 – 94% are stung by insect in hymenoptera family at least once in their lifetime1<br /> - In children prevalence rates are lower: questionnaires in several thousand girl and boy scouts in the USA and children in Europe resulted in a prevalence of only 0.15–0.3%.2<br />Epidemiology<br />1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />2. Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  22. 22. Sensitization 9.3 – 27.8% ( positive skin test or detection of specific IgE in patients with no previous case history or both)<br />Inchildren, inanunselectedItalianchildpopulationtheprevalenceofsensitization 3.7%<br />Epidemiology <br />1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
  23. 23. Large local reaction (LLR) : 2.4-26.4%<br /> - In children is 19% <br /> - 38% in beekeepers<br />Systemic reaction <br /> - 0.3-7.5%(European)<br /> - 0.5-3.3% ( USA)<br /> - children in only 0.15–0.8 %. (USA and Europe)<br />Epidemiology<br />1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
  24. 24. 1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
  25. 25. Anaphylactic shock was reported in 0.6–42.8% <br />Fatal rate 0.03-0.48 per 100,000 inhabitants per year ( in USA and Europe ) <br />40 to 85% of the subjects with fatal reactions after Hymenoptera stings had no documented history of previous anaphylactic reactions.<br />Epidemiology<br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  26. 26. Epidemiology in Thailand<br />Thammasat : Occurrencerateofanaphylaxisin ED;food 40%,drugs 36%,insects5%<br />Poachanukoon o, Asian Pac J Allergy Immunol. 2006 Jun-Sep;24(2-3):111-6<br />Siriraj: Incidencerateofanaphylaxis;drug35%,food28%,idiopathic15%,insect10%<br />BunsawansongW, J Allergy ClinImmunol 2005; 115:S39<br />Ramathibodi:Causeofanaphylaxis;food 41%, drugs 25%, insects 11.5%, radiocontrastmedia 4.2%, allergenextract 4.2% andbloodproducts 2.1%<br />Direkwattanachai C, J Allergy Clin Immunol 2005; 115:S39<br />
  27. 27. ANAPHYLAXIS IN ADMITED PATIENT A 5 YEARS EXPERIENCE IN CHONBURI HOSPITAL <br />The common causes of anaphylaxis was food (33%) and insect sting (29%).<br />Epidemiology in Thailand<br />
  28. 28. Clinical Presentation<br />
  29. 29. Local reaction<br />Most insect stings  local reactions<br /> - Redness<br /> - Swelling<br /> - Itching and pain<br />Large local reaction (late phase IgE mediated)<br /> - increase in size for 24 to 48 hours,<br /> - swelling >10 cm in diameter contiguous to the site of the sting, and<br /> - 5 to 10 days to resolve <br />The risk of developing a SR after a LLR is relatively low (5–15%) (in adult & children)<br />
  30. 30. Systemic reaction <br />Manifestations not contiguous with the site of the sting  mild to lifethreatening.<br /> - cutaneous: urticaria and angioedema<br /> - respiratory : bronchospasm, upper airway obstruction (eg, tongue or throat swelling and laryngeal edema) <br /> - cardiovascular :arrhythmias ,coronary artery spasm hypotension and shock <br /> - gastrointestinal : nausea, vomiting, diarrhea, and abdominal pain<br /> - neurological :seizures <br />
  31. 31. Non-allergic manifestations<br />No evidence that these are IgE mediated although the underlying mechanisms are not known.<br />
  32. 32. Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  33. 33. Rare : under-recognized.<br />Insect stings  one quarter of all anaphylactic deaths in the United Kingdom each year.<br />Average time from sting to death was 10–15min.<br />Fatal reaction<br />1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
  34. 34. 1.Epidemiology of insect-venom anaphylaxis ; CurrOpin Allergy ClinImmunol 2008, 8:330–337<br />
  35. 35. Risk factor of Hymenoptera Venom allergy <br />
  36. 36. Risk factor of Hymenoptera Venom allergy <br />The frequency of a systemic reaction is affected by the following factors<br />Time interval between sting<br />: Risk for SRs increased by 58% if preceded by sting with in 2 month<br /> : With increasing interval between stings the risk declines steadily, but remains in range of 20–30% even after 10 years.<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  37. 37. <ul><li>Sensitization to venom : Ig E sensitization a risk</li></ul> factor for subsequent SRs<br /><ul><li>Severity of the preceding reaction</li></ul> : After a large local reaction  5 -15% develop<br /> SR when next stung. <br /> : After Systemic reaction  40–60% develop<br /> SR when next stung. <br />
  38. 38. <ul><li>Insect : Bee venom > vespid for systemic reaction on next sting.
  39. 39. Bee keeper : Frequently stung </li></ul> < 15-25 sting per year  high risk of SR <br /> > 200 sting per year  protected<br /><ul><li>Atopy: Venom allergy not common in atopic individual </li></li></ul><li>The severity of a systemic reaction<br /><ul><li>Age : Major SR in pediatric  cutaneous</li></ul> Adult  Cardiovascular <br /><ul><li>Underlying Cardiac and respiratory disorder
  40. 40. Elevated Baseline tryptase and mastocytosis</li></ul>อธิบายแต่ละอัน<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  41. 41. Natural history of insect sting allergy: Relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactionsMD Robert E. Reisman (J Allergy Clin Immunol 1992;90:335-9) <br />Nature of the symptoms of initial insect sting anaphylaxis is related to the risk and severity of subsequent sting reactions<br />re-stings were analyzed in 220 patients (venom anaphylaxis + did not receive VIT ) <br />The incidence of a reaction after re-sting was 56% in the total group, was more frequent in adults (74%) than in children (40%)<br />
  42. 42. Natural history of insect sting allergy: Relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactionsMD Robert E. Reisman (J Allergy Clin Immunol 1992;90:335-9) <br />When re-sting reactions did occur, symptoms was similar to initial sting reaction.<br />The observations suggest that patients with mild to moderate symptoms probably do not require VIT<br />
  43. 43. Diagnosis<br />
  44. 44. Investigations for hymenoptera venom allergy<br />Detailed history <br /><ul><li>Date of sting reactions
  45. 45. Severity of symptoms
  46. 46. Interval between sting and the onset of symptom
  47. 47. Progression of reaction
  48. 48. Emergency treatment
  49. 49. Sting site
  50. 50. Retained or removed stinger
  51. 51. Environment and activities before sting
  52. 52. Risk factors of severe reaction
  53. 53. Risk factors for repeated re-stings
  54. 54. Tolerated stings after the first systemic reactions</li></ul>Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  55. 55. Demonstration of venom-specific immunoglobulin E <br />Skin test <br /> - immediately available <br /> - greater discrimination between bee and wasp sensitization than serum-specific IgE to whole venom<br /> - correlate with history<br />Investigations for hymenoptera venom allergy<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  56. 56. SPT with standardized venom extracts <br /> (0.01–100 mcg/mL) with both bee and wasp venoms<br />If SPT negative but strong clinical history  intradermal testing (IDT)<br /> - concentrations 0.001- 1mcg/mL venom<br /> - volume 0.03 mL of the extract<br /> - patients with Hx of severe anaphylaxis  lower starting<br />SRs reported during skin testing<br />Investigations for hymenoptera venom allergy<br />Diagnosis of Hymenoptera venom allergy ;Allergy 2005: 60: 1339–1349<br />
  57. 57. 2. Serum-specific IgE<br /><ul><li>level of ≥ 0.35 kU/L  positive
  58. 58. SPT and serum specific IgE not correlate with clinical, must be interpreted with clinical history
  59. 59. Double positivity (wasp and bee venom)  30%</li></ul>Investigations for hymenoptera venom allergy<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  60. 60. Baseline tryptase :<br />-patient with anaphylaxis to hymenoptera sting have an elevated ( ≥11.4 mg/L) baseline tryptase ‘mastocytosis’ spectrum  investigations (bone marrow examination)<br />Investigations for hymenoptera venom allergy<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  61. 61. - Patients with baseline tryptase with or without systemic mastocytosis develop more severe(cardiovascular reactions) >normal baseline tryptase group<br />Investigations for hymenoptera venom allergy<br />Potier A, Lavigne C, Chappard D et al.<br />Cutaneous manifestations in Hymenoptera<br />and Diptera anaphylaxis: relationship<br />with basal serum tryptase. Clin<br />Exp Allergy 2009; 39:717–25.<br />
  62. 62. Serum total specific IgE<br /> nonspecific <br /> total serum IgE of > 250 kU/L is more likely to indicate asymptomatic sensitization<br />BAT (Basophil activation test) <br />research tool <br />Surface expression of CD63/203c is used as a surrogate for basophil activation.<br />BAT correlates well with serum-specific IgE<br />Investigations for hymenoptera venom allergy<br />
  63. 63. Sting challenge test <br />Untreated patients with or without a history of anaphylactic sting reactions, to identify who need immunotherapy.<br />patients on maintenance VIT to identify who are not yet protected.<br />performed 1 year or more after stopping VIT to monitor the duration of the protection by treatment, restricted to scientific studies<br />
  64. 64. Management<br />
  65. 65. 1.Treatment of acute reaction <br />
  66. 66. Provision of management plan<br /> - Treatment plan :antihistamine used, self-injectable adrenaline, supine posture with legs raised.<br /> - Children liaison with the school<br /> - Patients with previous SRs  wear a medical alert bracelet.<br />2. Prevention <br />
  67. 67.
  68. 68. Patients who have had a systemic reaction from an insect sting and have venom-specific IgE antibodies<br />The goals of VIT <br /> 1) prevent systemic reactions and <br /> 2) alleviate patients’ anxiety related to insect stings.<br />3.Venom immunotherapy<br />Stinging insect hypersensitivity: <br />A practice parameter<br />update 2011<br />
  69. 69. Theodore M.Freeman. N Engl J Med2004;351:1978-84.<br />
  70. 70. The risk of non treatment includes the chance of future<br />stings causing either mild reactions or life-threatening<br />anaphylaxis, as well as impaired health-related quality of<br />life. Prediction of risk on future stings is based primarily<br />on the severity of the past reaction, the level of sensitivity<br />measured by skin test or RAST, the age of the patient, and<br />the degree of exposure <br />David B.K Golden.J Allergy ClinImmunol 2005;115:439-47.<br />
  71. 71.
  72. 72. Prospective studies have shown that patients 16 years of age and younger who have experienced cutaneous systemic reactions without other allergic manifestations have approximately a 10% chance of having a systemic reaction if re-stung. <br /> If a systemic reaction does occur, it is likely to be limited to the skin, with less than a 5% risk of a more severe reaction and less than a 1% risk of life-threatening anaphylaxis.<br />Indications for venom immunotherapy in children<br />
  73. 73.
  74. 74.
  75. 75. Between 1978 and 1985,diagnosed allergic reaction to insect stings in 1033 children, of whom 356 received venom immunotherapy<br />telephone and mail between January 1997 and January 2000, to determine the outcome of stings that occurred in the period from 1987 through 1999.<br />N Engl J Med 2004;351:668-74.<br />
  76. 76. N Engl J Med 2004;351:668-74.<br />
  77. 77. N Engl J Med 2004;351:668-74.<br />
  78. 78. VIT is generally not necessary for patients 16 years of age and younger who have experienced only cutaneous systemic reactions (C) <br />Sting insect hypersensitivity : A practice parameter update 2011<br />Sting insect hypersensitivity : A practice parameter update 2011<br />N Engl J Med 2004;351:668-74.<br />
  79. 79. Adults who have experienced only cutaneous manifestations to an insect sting are generally considered candidates for VIT, although the need for immunotherapy in this group of patients is controversial. (D)<br />Sting insect hypersensitivity : A practice parameter update 2011<br />
  80. 80. The New England Journal of Medicine ;1994<br />
  81. 81. - VIT usually not indicated for sting-induced cutaneous SRs but may be considered in<br /> raised baseline tryptase<br />  age<br />  likelihood of future stings (bee keeping, or <br /> occupational exposure) <br /> effect on QOL<br /> patient preference <br /> morbid conditions.<br />Diagnosis and management of hymenoptera venom allergy: BSACI guidelines Clinical & Experimental Allergy, 41, 1201–1220<br />
  82. 82. VIT is generally not necessary in patients who have experienced only large local reactions to stings but might be considered in those who have frequent unavoidable exposure. (B)<br />The risk of systemic reaction in patients with a history of large local reactions in most studies is no more than 5% to 10%<br />Sting insect hypersensitivity : A practice parameter update 2011<br />
  83. 83. Venom immunotherapy reduces large local reactions to insect stings(J Allergy ClinImmunol 2009;123:1371-5.)<br />
  84. 84. Selection of venom to be used in immunotherapy<br />Honeybeeandbumblebeevenomsshowmarkedcross-reactivity<br />Venomimmunotherapywithhoneybeevenomalonewillbesufficient.<br />B. M. Bil, F. Rueff, H. Mosbech,F. Bonifazi, J. N. G. Oude-Elberink,the EAACI Interest Group on Insect Venom Hypersensitivity. Allergy 2005;60:1459-70.<br />
  85. 85. Selection of venom to be used in immunotherapy<br />Cross-reactivityexistsbetweenthemajorvenomcomponentsofseveralvespids, particularlybetweenVespula, DolichovespulaandVespavenoms<br />Most common therapy for vespid sensitivities is with the mixed vespid venoms<br />B. M. Bil, F. Rueff, H. Mosbech,F. Bonifazi, J. N. G. Oude-Elberink,the EAACI Interest Group on Insect Venom Hypersensitivity. Allergy 2005;60:1459-70.<br />
  86. 86. Selection of venom to be used in immunotherapy<br />Inthecaseofdouble-positiveteststohoneybeeandVespulaRAST-inhibitionassayswillhelptodistinguishbetweencross-reactivityanddoublesensitization<br />Treatmentwithbothvenomsisonlyindicatedindocumenteddoublesensitization<br />B. M. Bil, F. Rueff, H. Mosbech,F. Bonifazi, J. N. G. Oude-Elberink,the EAACI Interest Group on Insect Venom Hypersensitivity.Allergy2005;60:1459-70.<br />
  87. 87. VIT should usually be continued for at least 3 to 5 years. Although most patients can then safely discontinue VIT, some patients might need to continue VIT for an extended period of time or indefinitely. (C)<br />Duration of VIT<br />Sting insect hypersensitivity : A practice parameter update 2011<br />
  88. 88. <ul><li>SR to re-sting discontinuing VIT were reported on only 4.8% of 82 patients with a VIT duration of ≥50 months as opposed to 17.8% of 118 with a VIT duration of 33–49 months</li></ul>Duration of VIT<br />The evaluation of the common diagnostic methods of hypersensitivity for bee and yellow jacket venom by means of an in-hospital insect sting. <br />J Allergy ClinImmunol 1985;75:556–562.<br />
  89. 89. David B. K. Golden. AnneKagey-Sobotka.Lawrence M. LichtensteinJ Allergy ClinImmunol 2000;105:389.<br />
  90. 90. Studies of immunotherapy with 100 mcg dose of individual venom have been associated with 75-95% efficacy <br />( Middleton’s allergy principle and practice 7 thadition ; p 1012)<br />In prospective uncontrolled studies with sting provocation tests during immunotherapy 0–9% of vespid-allergic individuals but around 20% of bee venom-allergic patients still reacted to the challenge.<br />Efficacy of VIT<br />B. M. Bil, F. Rueff, H. Mosbech,F. Bonifazi, J. N. G. Oude-Elberink,the EAACI Interest Group on Insect Venom Hypersensitivity.Allergy2005;60:1459-70.<br />
  91. 91. Safety<br />3-12%ofpatientshavetreatment-inducedsystemicreactionsthatgenerallyaremildandoccurintheearlyphasesofVIT<br />Thelargelocalreactionsthatoccurin 25%ofchildrenand 50%ofadults, usuallyatdosesabout20-30 mcg<br />PretreatmentwithantihistaminesreducesVITreactionsandmayimprovetheefficacyofVIT<br />Honeybee-sensitivepatientshavemorereactionstoVIT(41%versus25%)thanthoseonvespidVIT<br />David F. Graft.Med Clin N Am 2006;90:211-32<br />
  92. 92. Protocal schedules for VIT in US<br /><ul><li>Build up dose injected VIT 1-2 time/wk (21 wk)
  93. 93. Start concentration 0.1-1mcg/ml</li></ul>- Maintenain dose 100 mcg/ml <br />- US FDA approved every 4 wk<br /><ul><li>Duration of IT for 3-5 year </li></li></ul><li>Protocal schedules for VIT in UK <br /><ul><li>Build up injected VIT every 1 wk</li></ul> ( 12 wk)<br /><ul><li>Maintenance 100 mcg/ml every 4-8 wk
  94. 94. Duration 3 year (recommented ), mostly receive 3-5 years</li></li></ul><li>Rush<br />Ultrarush<br />
  95. 95. symptoms of initial insect sting is related to the risk and severity of subsequent sting reactions<br />Systemic Reaction after subsequence more frequent in adults ( 60 %) than in children (40%) <br />The risk of systemic reaction in patients with a history of large local is no more than 5% to 10%<br />Take home message<br />
  96. 96. Patients who have had a systemic reaction from an insect sting and have venom-specific IgE antibodies  candidate for VIT <br />VIT is generally not necessary for patients 16 years of age and younger who have experienced only cutaneous systemic reactions<br />Take home message<br />
  97. 97. Thank you for your attention <br />

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