INSECT ALLERGY
CHULEEPORN KONGMEESOOK ,MD
Outline
Epidemiology
Clinical presentations
Diagnosis
Treatment
Apidae

Vespidae

Formocidae

Pesek et al. Allergy Asthma Immunol Res. 2013 May;5(3):129-137.
May;5 ):129-137.
Bilό et al....
Apidae
Vespidae
Formicidae
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.
...
Cross reactivity 1
Double or even multiple positive tests
can be caused by true double
sensitization or by cross-reactive
...
Cross reactivity 2
Within Apidae family
Venoms and major allergens of different
honeybees worldwide very similar
(Phosphol...
Cross reactivity 3
Within vespid venoms
CrossCross-reactivity among vespids is strong,
due to similarities of venom compos...
Cross reactivity 4
Between venoms of Apidae and Vespidae
Hyaluronidase (major crossreactive
component) 50% sequence identi...
Epidemiology 1
Depending on country’s climate.
56.
56.6 – 94.5% stung by Hymenoptera insect
94.
at least once in live.
Pre...
Epidemiology 2
Systemic allergic reactions up to 3% of
adults and 1% of children.
Large local reactions uncertain, estimat...
Epidemiology in Thailand 1
Chulalongkorn
Etiologies of anaphylaxis : Drug 48 %,
Food 31 %, Contrast media 6 %, Unknown
5 %...
Epidemiology in Thailand 2
Siriraj
Causes of Anaphylaxis : Drugs 50 %,
Foods 24 %, Idiopathic 15 % and Insect
stings/bites...
Epidemiology in Thailand 3
Thammasat
Causes of Anaphylaxis : Foods 40 %,
Drugs 36 %, Unidentified 17 % and
Hymenoptera 5 %...
เดลิ นิวส์ 24 เมษายน 2556
Clinical presentations
Local reaction
Large local reaction
Systemic reaction
Unusual reaction

Lieberman P In: Allergy: Pr...
Risk factors of Hymenoptera venom allergy
Time interval between stings, number of
stings
Venom sensitization
Severity of p...
Diagnosis
Clinical history
Skin tests
In vitro tests
Sting challenge test

Lieberman P In: Allergy: Principles and Practic...
Treatment of acute reactions

www.eaaci.net
Preventing insect stings

www.cdc.gov
Preventing fire ant stings and bites

www.cdc.gov
Venom immunotherapy 1
Indication
History of previous systemic reaction to a
sting and evidence of venom-specific IgE
venom...
www.eaaci.net
Bovie RJ et al. The Cochrane Collaboration 2012 ;1-70.
70.
Valentine et al. N Engl J Med 1990;323:1601-3.
1990;323:1601-
David B.K. Golden et al N Engl J Med 2004;351:668-74.
2004;351:668-74.
Venom immunotherapy 2
Selection of venom in honey bee and
bumblebee
Marked cross-reactivity.
crossHoneybee venom alone wil...
Venom immunotherapy 3
Selection of venom in vespids
CrossCross-reactivity exists between major
venom components of several...
Venom immunotherapy 4
Selection of venom in Apidae and Vespidae
CrossCross-reactivity very limited
limited.
Treatment with...
Venom immunotherapy 5
Duration of venom immunotherapy
Should continued at least 3 - 5 years.
Some patients need to continu...
GOLDEN ET AL J Allergy Clin Immunol 2000;105:385-90
2000;105:385-
Venom immunotherapy 6
Efficacy
95–100%
95–100% effective in preventing systemic
reactions to stings.
100 µg dose of indivi...
Venom immunotherapy 7
Safety
Systemic symptoms occur in 5–15% during
15%
initial weeks of treatment.
Pretreatment with ant...
Venom immunotherapy 8
Treatment protocol
Traditional regimen
Modified rush
Rush regimen
UltraUltra-rush regiment

Lieberma...
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;
S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167
2013;
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4
127:852-
Take Home Message
Systemic reaction from insect sting
and venom-specific IgE antibodies should
venomreceive VIT.

VIT shou...
THANK YOU
Insect sting allergy
Insect sting allergy
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Insect sting allergy

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Insect sting allergy

Presented by Chuleeporn Kongmeesook, MD,

2013

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Insect sting allergy

  1. 1. INSECT ALLERGY CHULEEPORN KONGMEESOOK ,MD
  2. 2. Outline Epidemiology Clinical presentations Diagnosis Treatment
  3. 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. 4. Apidae
  5. 5. Vespidae
  6. 6. Formicidae
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 17. เดลิ นิวส์ 24 เมษายน 2556
  18. 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. 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. 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. 21. Treatment of acute reactions www.eaaci.net
  22. 22. Preventing insect stings www.cdc.gov
  23. 23. Preventing fire ant stings and bites www.cdc.gov
  24. 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. 25. www.eaaci.net
  26. 26. Bovie RJ et al. The Cochrane Collaboration 2012 ;1-70. 70.
  27. 27. Valentine et al. N Engl J Med 1990;323:1601-3. 1990;323:1601-
  28. 28. David B.K. Golden et al N Engl J Med 2004;351:668-74. 2004;351:668-74.
  29. 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. 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. 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. 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. 33. GOLDEN ET AL J Allergy Clin Immunol 2000;105:385-90 2000;105:385-
  34. 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. 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. 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. 37. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  38. 38. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  39. 39. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  40. 40. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  41. 41. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167 2013;
  42. 42. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167 2013;
  43. 43. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167 2013;
  44. 44. S.C. Stokes et al. Ann Allergy Asthma Immunol 2013;110 :165 -167 2013;
  45. 45. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  46. 46. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  47. 47. GOLDEN ET AL J ALLERGY CLIN IMMUNOL 2011 ;127:852-4 127:852-
  48. 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. 49. THANK YOU

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