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Venom Allergy: Overview, Diagnosis, and Treatment

About Venom Allergy

Insect venom allergy can develop at any age. It may take several uneventful stings for manifestations to appear. After an initial sting, the immune system of an affected patient may respond by producing IgE antibodies. Any subsequent stings can trigger a systemic inflammatory response.1

It is important to correctly identify the culprit insect, as patients can be allergic to one or several species of stinging insects.1 It is also important to educate patients who work as beekeepers or greenhouse workers, or who participate in outdoor exercise, as their occupations and hobbies put them at increased risk for receiving a sting.1 Testing can be used to identify the insects to which a patient is sensitized, which will aid in the selection of the most appropriate treatment.2

24 to 48 hours

Symptoms typically peak between 24 and 48 hours after the sting.1

Venoms from the Hymenoptera order of insects—commonly known as bees, wasps, and some ants—may trigger systemic allergic reactions in some patients.

These reactions, including anaphylaxis, can be severe and fatal even on the first exposure.Systemic reactions occur in approximately less than 1 percent of children, compared with around 3 percent of adults.3 Systemic reactions to a sting are most often IgE-mediated.1

Allergic reactions to bee or wasp venom can also be localized to the sting and can vary in severity.1 Patients experiencing a large local reaction will usually experience edema, erythema, and pruritus rapidly after the sting.1 These symptoms typically peak between 24 and 48 hours after the sting.1


For many insect venom-sensitized patients, an anaphylactic reaction after a sting is a traumatic event resulting in an altered quality of life. The purpose of venom hypersensitivity diagnosis is to classify a sting reaction by history, identify the underlying pathogenesis, and identify the offending insect. Systemic anaphylactic reactions are most often IgE mediated.1
 

Venom allergy: Refining differential diagnosis through testing

Systemic reactions can be measured using the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System, with severity ranges from grade I to grade IV:5

  • Grade I: Generalized pruritus, urticaria, flushing, or sensation of heat or warmth; or angioedema (not laryngeal, tongue or uvular); or upper respiratory symptoms including rhinitis (e.g., sneezing, rhinorrhea, nasal pruritus, and/or nasal congestion), or throat-clearing (itchy throat), or cough perceived to originate in the upper airway (not the lung, larynx, or trachea); or conjunctival symptoms including erythema, pruritus, or tearing; or nausea, metallic taste, or headache.
  • Grade II: Symptoms associated with grade I reactions as well as generalized edema, tightness in the chest, wheezing, abdominal pain, nausea and vomiting, and dizziness.
  • Grade III: Symptoms associated with grade I or II reactions as well shortness of breath (dyspnea), trouble with speech articulation (dysarthria), hoarseness, weakness, confusion, and a feeling of impending doom.
  • Grade IV: Symptoms associated with grade I, II, or III reactions as well as loss of consciousness, incontinence, or blue, discolored skin (cyanosis).


Who should be tested?

Diagnostic tests should be carried out in all patients with a history of a systemic sting reaction to detect sensitization. As venom immunotherapy (VIT) is indicated in patients with a history of severe systemic reactions and documented sensitization, it is imperative to correctly identify the offending insect.
 

What is component testing?

What is component testing?

Managing patients with stinging insect allergies can be challenging.

  • Did they react to a sting from a wasp or a bee? Many patients just aren’t sure
  • Up to 50 percent of patients with insect venom allergy test positive for both bee and wasp venom sensitization1.
  • This makes it challenging to prescribe the most effective form of immunotherapy.

But there’s a better option: testing with specific IgE stinging insect allergen components. Component allergen testing can help determine the specific venom sensitization and appropriate treatment plan. This testing can not only assist with discrimination between true sensitization and cross-reactivity of native whole venom extracts, but can also facilitate accurate prescription of venom immunotherapy (VIT). VIT with the culprit venom offers a high degree of protection from future anaphylactic sting reactions.2,3

honey bee

80-84% protection in bee venom allergy1

yellow jacket

90-95% protection in yellow jacket venom allergy1

 

By detecting sensitization with stinging insect allergen component testing, a more precise diagnosis and treatment plan is possible.2,3

It’s not just knowledge you’ll be giving them, but peace of mind, too.

Tryptase

International guidelines recommend that tryptase should be analyzed in patients with a history of a severe sting reaction and that tryptase should be measured in patients before starting VIT. 2, 6-9

Tryptase measures the total tryptase levels including all forms of α-tryptase and ß-tryptase. The baseline level of tryptase in the circulation reflects the number of mast cells. Elevated baseline levels of tryptase are an indication of mastocytosis and measurement of tryptase is recognized by the World Health Organization (WHO) as a minor diagnostic criterion of the disease.10

Venom allergy and quality of life

Allergy to insect venom has been reported to cause emotional distress in patients leading to a decrease in their quality of life,4 so communicating the most effective management strategy can help alleviate the fear associated with another potential reaction.

Common allergens

Stinging insects most likely to cause a reaction may include:4

  • Wasps
  • Yellow jackets
  • Paper wasps
  • Honeybees
  • Bumblebees
  • Stinging ants (e.g., fire ants, jack jumper, and bull ants)

Testing Confidence

Testing Increases Diagnostic Confidence

Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv 

i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238

Get scientific information on more than 550 allergens.

Learn more about testing.

 

Management and care for patients with venom allergy

Venom immunotherapy (VIT) is the go-to treatment option for patients with a venom allergy. It has been shown to reduce the risk for future systemic reactions and the severity of a systemic reaction when one occurs.5 That is why guidelines recommended VIT as an option for the treatment of IgE-mediated bee and wasp venom allergy in patients who have had a:7

  • Severe reaction to bee or wasp venom

OR

  • Moderate systemic reaction to bee or wasp venom and who also have additional risk factors, such as a high baseline serum tryptase, a high risk for future stings, or whose quality of life is significantly affected by venom allergy

VIT is most appropriate for patients with a sensitization to bee and wasp venom, as such, making a distinction between cross-reactivity and genuine double-sensitization is critical.2,7,11,12 Up to 50 percent of venom-allergic patients have positive whole allergen test results to both bee and wasp venom extracts.12 Successful VIT is more likely when treatment selection is based on specific sensitization to bee and/or wasp venom.7

Practice parameters have been developed to help guide the management and treatment of patients with venom allergies.

Practice Parameters

Practice parameters and guidelines

for venom allergy:

References

 

  1. Pawankar R, Holgate S, Canonica G, at el. World Allergy Organization. White Book on Allergy (WAO). 2011. http://www.worldallergy.org/UserFiles/file/WAO-White-Book-on-Allergy_web.pdf. Accessed December 2017.
  2. Biló B, Rueff F, Mosbech H, et al. Diagnosis of Hymenoptera venom allergy. Allergy. 2005; 60(11):1339-1349.  
  3. Golden DBK. Insect Sting Anaphylaxis. Immunol Allergy Clin North Am. 2007 May;  27(2): 261–vii. 
  4. Ludman SW, Boyle RJ. Stinging insect allergy: current perspectives on venom immunotherapy. J Asthma Allergy. 2015;8:75-86.
  5. Cox L, Larenas-Linnemann D, Lockey RF, et al. Speaking the same language: The World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System. J Allergy Clin Immunol. 2010;125(3):569-74. 
  6. Cox L, Nelson H, Lockey R. Allergen immunotherapy: A practice parameter third update. J Allergy and Clin Immuno. 2011; 127(1):1-55.
  7. Bonifazi F Jutel M, Biló BM, et al. Prevention and treatment of hymenoptera venom allergy: guidelines for clinical practice. Allergy. 2005; 60(12):1459- 1470. 
  8. Simons FE, et al. World Allergy Organ J. 2014;7(1):9.
  9. Simons FE, et al. Int Arch Allergy Immunol. 2013;162(3):193-204.
  10. ImmunoCAP® Tryptase DFU, https://dfu.phadia.com/Data/Pdf/5db0691d89c23208b8036f94.pdf
  11. Spillner E, Blank S, Jakob T. "Hymenoptera allergens: from venom to "venome." Front Immunol. 2014;28;5:77. 
  12. Mittermann I, Zidarn M, Silar M, et al. Recombinant allergen-based IgE testing to distinguish bee and wasp allergy. J Allergy Clin Immunol. 2010;125:9(6) 1300-1307.