Insect Sting Allergy and Venom Immunotherapy

Insect Sting Allergy and Venom Immunotherapy
By: David B.K. Golden, M.D.
Johns Hopkins University, Baltimore


History of Reaction to Insect Stings (Skin Test Positive Patients)

No reaction
Large Local
Cutaneous Systemic
Anaphylaxis

Severe swelling 24 hrs after a sting should be treated with:
A. Antibiotics C. Antihistamine E. Epinephrine
B. Prednisone D. Venom immunotherapy

Venom immunotherapy:
A. Is not necessary (“He’ll outgrow it”) B. Is dangerous
C. is only partially effective D. Is forever E. None of the above

Diagnosis of Insect Sting Allergy (Indications for Venom Immunotherapy)
Symptoms and Signs of Insect Sting Anaphylaxis in Adults and Children
Symptoms or Sign
Cutaneous only
Urticaria/angioedema
Dizziness/hypotension
Dyspnea/wheezing
Throat tightness/
Hoarseness
Loss of consciousness

Epidemiology of Venom Allergy
* History of systemic reaction in 0.5%-3.0% of the population
* Positive venom skin test or RAST in 15%-25% of the population.
* Transient positive skin test or RAST may occur after uneventful sting.
* Presence of IgE venom antibody not necessarily predictive of clinical reactivity.

Correlation of Yellow Jacket Venom
RAST and Skin Tests
History Positive Patients with Negative Venom Skin Tests
Possible explanations:
Not true allergic reaction (no objective signs)
Allergy “outgrown”
Mastocytosis (~1 % of insect allergic patients)
Not detected:
Diagnostic Venom Test Reactivity after Systemic Sting Reaction
Venom Skin Test / RAST in History Positive Patients
Total history positive patients screened:
Diagnosis of Insect Allergy in Patients With Positive History (Systemic)
Skin test positive
ST negative /
Low Risk Sub-Groups of Patients With Positive Venom Skin Tests
Insect Sting Allergy in Children
Summary Of Sting Reactions
Natural History of Large Local Reactions
Repeat Systemic Reaction In Sting Allergic Patients
Risk of Systemic Reaction in
Untreated Skin Test Positive Patients
Controlled Trial of Venom Immunotherapy
Venom Immunotherapy Treatment Protocols
Dose Response of Venom Immunotherapy
Premedication During Venom Immunotherapy
Venom-IgE and Skin Test During
and After Venom Immunotherapy
Discontinuing Venom Immunotherapy:
Reported Studies and Criteria
Discontinuing Venom Immunotherapy

Insect Sting Allergy and Venom Immunotherapy.ppt