1.
INSECT ALLERGY
CHULEEPORN KONGMEESOOK ,MD

2.
Outline
Epidemiology
Clinical presentations
Diagnosis
Treatment

3.
Apidae
Vespidae
Formocidae
Pesek et al. Allergy Asthma Immunol Res. 2013 May;5(3):129-137.
May;5 ):129-137.
Bilό et al. Allergy 2005;60: 1339–1349.
Bilό
2005;60: 1339–1349.

4.
Apidae

5.
Vespidae

6.
Formicidae

7.
Pesek et al. Allergy Asthma Immunol Res. 2013 May;5(3):129-137.
May;5 ):129-137.
Bilό et al. Allergy 2005; 60: 1339–1349.
Bilό
2005; 60: 1339–1349.

8.
Cross reactivity 1
Double or even multiple positive tests
can be caused by true double
sensitization or by cross-reactive
crossIgE antibodies.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

9.
Cross reactivity 2
Within Apidae family
Venoms and major allergens of different
honeybees worldwide very similar
(Phospholipase A2).
Bumblebee PLA2 is only 53%.
PLA2
53%.
Immunologic cross-reactivity exist between
crosshoneybee and bumblebee venoms
venoms.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

10.
Cross reactivity 3
Within vespid venoms
CrossCross-reactivity among vespids is strong,
due to similarities of venom composition
and structure of single allergens.
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

11.
Cross reactivity 4
Between venoms of Apidae and Vespidae
Hyaluronidase (major crossreactive
component) 50% sequence identity between
component) 50%
honeybee and vespid venoms
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

12.
Epidemiology 1
Depending on country’s climate.
56.
56.6 – 94.5% stung by Hymenoptera insect
94.
at least once in live.
Prevalence 9.3 - 28.7% in adult.
28.
Bilό et al. Allergy and Clinical Immunology 2008 ; 8:330–337
Bilό
330–

13.
Epidemiology 2
Systemic allergic reactions up to 3% of
adults and 1% of children.
Large local reactions uncertain, estimated
10%
10% in adults.
Fatal stings at least 40 each year in USA and
16–
16–38 in France.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

14.
Epidemiology in Thailand 1
Chulalongkorn
Etiologies of anaphylaxis : Drug 48 %,
Food 31 %, Contrast media 6 %, Unknown
5 % and Insect sting 4 %.
Techapornroong M et al Asian Pac J Allergy Immunol 2010;28:262-9.
2010;28:262-

15.
Epidemiology in Thailand 2
Siriraj
Causes of Anaphylaxis : Drugs 50 %,
Foods 24 %, Idiopathic 15 % and Insect
stings/bites 11 %.
Jirapongsananuruk O et al Ann Allergy Asthma Immunol. 2007;98:157–162.
2007;98:157–162.

16.
Epidemiology in Thailand 3
Thammasat
Causes of Anaphylaxis : Foods 40 %,
Drugs 36 %, Unidentified 17 % and
Hymenoptera 5 %.
Poachanukoon O et al ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY 2006; 24:111-116 .
2006; 24:111-

17.
เดลิ นิวส์ 24 เมษายน 2556

18.
Clinical presentations
Local reaction
Large local reaction
Systemic reaction
Unusual reaction
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

19.
Risk factors of Hymenoptera venom allergy
Time interval between stings, number of
stings
Venom sensitization
Severity of preceding reaction
Age
Cardiovascular diseases, b-blockers
bInsect
Elevated serum tryptase, mastocytosis
tryptase,
M. T. Krishna et al Clinical & Experimental Allergy 2011 ;41:1201–1220.
41:1201–1220.
Bilό et al. Clinical & Experimental Allergy 2009 ;39: 1467–1476
Bilό
39: 1467–
Bilό et al. Allergy 2005; 60: 1339–1349
Bilό
2005; 60: 1339–

20.
Diagnosis
Clinical history
Skin tests
In vitro tests
Sting challenge test
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

21.
Treatment of acute reactions
www.eaaci.net

22.
Preventing insect stings
www.cdc.gov

23.
Preventing fire ant stings and bites
www.cdc.gov

24.
Venom immunotherapy 1
Indication
History of previous systemic reaction to a
sting and evidence of venom-specific IgE
venomantibodies.
Goal
Prevent systemic reactions.
Alleviate patients’ anxiety related to
insect stings.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

25.
www.eaaci.net

26.
Bovie RJ et al. The Cochrane Collaboration 2012 ;1-70.
70.

27.
Valentine et al. N Engl J Med 1990;323:1601-3.
1990;323:1601-

28.
David B.K. Golden et al N Engl J Med 2004;351:668-74.
2004;351:668-74.

29.
Venom immunotherapy 2
Selection of venom in honey bee and
bumblebee
Marked cross-reactivity.
crossHoneybee venom alone will be sufficient.
Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

30.
Venom immunotherapy 3
Selection of venom in vespids
CrossCross-reactivity exists between major
venom components of several vespids.
vespids.
Most common therapy for vespid
sensitivity is mixed vespid venoms.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

31.
Venom immunotherapy 4
Selection of venom in Apidae and Vespidae
CrossCross-reactivity very limited
limited.
Treatment with both venoms only indicated in
double sensitization.
Bonifazi et al. Allergy 2005; 60: 1459–1470
2005; 60: 1459–

32.
Venom immunotherapy 5
Duration of venom immunotherapy
Should continued at least 3 - 5 years.
Some patients need to continue for
extended period of time or indefinitely.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

33.
GOLDEN ET AL J Allergy Clin Immunol 2000;105:385-90
2000;105:385-

34.
Venom immunotherapy 6
Efficacy
95–100%
95–100% effective in preventing systemic
reactions to stings.
100 µg dose of individual venoms
(honeybee, yellow jacket or Polistes wasp)
have 75–95% efficacy.
75–95% efficacy.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

35.
Venom immunotherapy 7
Safety
Systemic symptoms occur in 5–15% during
15%
initial weeks of treatment.
Pretreatment with antihistamines reduce
local and systemic reactions, and may
reduce frequency of systemic reactions.
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

36.
Venom immunotherapy 8
Treatment protocol
Traditional regimen
Modified rush
Rush regimen
UltraUltra-rush regiment
Lieberman P In: Allergy: Principles and Practice. Elsevier Inc, 2009. p. 1005-17
2009.
1005-

37.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

38.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

39.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

40.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

41.
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

42.
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

43.
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

44.
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;

45.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

46.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

47.
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-

48.
Take Home Message
Systemic reaction from insect sting
and venom-specific IgE antibodies should
venomreceive VIT.
VIT should continue for at least 3-5 yrs.

49.
THANK YOU