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Insect Sting Allergy and Venom Immunotherapy. 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.

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Insect Sting Allergy and Venom Immunotherapy

David B.K. Golden, M.D.

Johns Hopkins University, Baltimore


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

No reaction

Large Local

Cutaneous Systemic

Anaphylaxis


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Severe swelling 24 hrs after a sting should be treated with:

A. Antibiotics C. Antihistamine E. Epinephrine

B. Prednisone D. Venom immunotherapy


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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


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Diagnosis of Insect Sting Allergy(Indications for Venom Immunotherapy)

  • History

  • Venom Skin Test (RAST)

  • Natural History


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Symptoms and Signs of Insect Sting Anaphylaxis in Adults and Children

Frequency (%)

Symptoms or Sign Adults Children

Cutaneous only 15 60

Urticaria/angioedema 80 95

Dizziness/hypotension 60 10

Dyspnea/wheezing 50 40

Throat tightness/ 40 40

Hoarseness

Loss of consciousness 30 5


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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.


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Correlation of Yellow Jacket Venom RAST and Skin Tests (Golden - JAMA 1989)

VenomSkin Test

RAST (ng/L) Positive Negative

< 1 (negative) 9 (24%) 190 (89%)

≥ 1 (positive) 29 (76%) 23 (11%)

1.0 - 1.9 8 9

2.0 - 2.9 5 4

3.0 - 4.9 4 5

≥5.0 12 5

Total 38 213


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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:

- Refractory period (anergy)

- RAST positive


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Diagnostic Venom Test Reactivity after Systemic Sting Reaction(Goldberg and Confino-Cohen; JACI 1997)

Time after sting 1 week 4 - 6 week Any

Skin Test Positive 20 (53%) 15 (39%) 35 (92%)

RAST Positive 24 (63%) 8 (21%) 32 (84%)

Any Positive 30 (79%) 8 (21%) 38 (100%)


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Venom Skin Test / RAST in History Positive Patients (Golden - JACI 2001)

Total history positive patients screened: (N=307)

ST positive 208 (68%)

ST negative 99 (32%)

ST - neg/RAST neg 56 (57%) (18%)

ST - neg/RAST positive 43 (43%)

RAST 1 - 3 ng/ml 36

RAST 7 - 243 ng/ml 7


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Diagnosis of Insect Allergy in Patients With Positive History (Systemic)

Skin test positive 68%

ST negative /

RAST positive 14%

ST neg / RAST neg /

sting challenge positive 1%

No sting allergy 17%


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Low Risk Sub-Groups of Patients With Positive Venom Skin Tests

Risk of

Sting Reaction History Systemic Reaction

Children - Cutaneous Systemic 10 %

Large Local 5 - 10 %


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Insect Sting Allergy in Children (1978 -1987)(Schuberth, Valentine, Kagey-Sobotka, Lichtenstein)

History N Disposition of Patients

Cutaneous 462 Untreated vs. VIT

systemic • untreated (n=352)

• treated (VIT) (n=110)

Mod-severe 345 VIT advised

systemic • untreated (n=99)

• treated (VIT) (n=246)

Large Local 226 No VIT

TOTAL 1033


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Summary Of Sting Reactions490 Stings in 180 Patients over 9 Yrs


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Natural History of Large Local Reactions

Diagnostic Test Sting Reaction

Skin Test RAST Systemic LL

Graft et al

(J Ped 1984) 105/125 2/54 20/54

children (84%) (4%) (37%)

Mauriello et al

(JACI 1984) 105/133 67/133 1/28 21/28

adults and children (79%) (50%) (4%) (75%)

Golden et al

(JACI 1984) 38/52 5/52

adults (73%) (10%)

Abrecht et al

(Clin Allergy 1980) 27/40 29/40

children and adults (68%) (73%)


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Repeat Systemic Reaction In Sting Allergic Patients

STUDY (YEAR) N SYSTEMIC (%)

GOLDEN (1981) 115 75 (65%)

HUNT (1978) 23 19 (61%)

SETTIPANE (1979) 119 72 (61%)

LANTNER (1989) 18 11 (61%)

REISMAN (1992) 220 124 (56%)

GALATAS (1994) 27 13 (48%)

PARKER (1982) 16 7 (44%)

DVORIN (1984) 19 8 (42%)

BLAAUW (1985) 86 29 (39%)

FRANKEN (1994) 228 90 (39%)

vanderLINDEN (1994) 324 96 (30%)

TOTAL 1195 544 (46%)


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Risk of Systemic Reaction in Untreated Skin Test Positive Patients

Original Sting ReactionRisk of Systemic Reaction

Severity Age 1 - 9 yrs 10 - 20 yrs

No reaction Adult 17 %

Large local All 10 % 10 %

Cutaneous Child 10 % 5 %

systemic Adult 20 % 10 %

Anaphylaxis Child 40 % 30 %

Adult 60 % 40 %



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Venom Immunotherapy Treatment Protocols

Conservative Moderate Liberal

Regimen Traditional Modified Rush Rush

Weeks to Mc 20 - 26 8 1

Dose (µg) 50 100 200

Maintenance (wks) 4 6 - 8 12


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Dose Response of Venom Immunotherapy(Rueff et al JACI 2001;108:1027-32.)


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Premedication During Venom Immunotherapy

TerfenadinePlacebo

Brockow et al (JACI 1997)

Systemic during VIT 1/82 (1%) 6/39 (15%)

Large Local during VIT 20/80 (24%) 17/39 (45%)

Muller et al (JACI 2001)

Systemic during VIT 5/24 (21%) 13/23 (56%)

Systemic to challenge sting 0/20 6/21 (28%)


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Venom-IgE and Skin Test During and After Venom Immunotherapy


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Author Patients Criteria

Studied Proposed

Graft (1984) children 5-7 years* 5 years

Urbanek (1985) children RAST neg RAST neg

Randolph (1986) adults & children RAST neg RAST neg

Keating (1991) adults & children 2-10 years* 5 years

Haugaard (1991) adults 3-7 years* 3 years

Muller (1991) adults & children 3-10 years* 3 years*

Reisman (1993) adults & children 1-6 years 3+ years

Lerch (1998) adults & children 3-10 years* 5 years#

Golden (1998) adults 5-7 years 5 years#

* Negative sting challenge included as criterion for discontinuation.

# Excluding patients with life-threatening history, honeybee allergy or systemic reaction during VIT.

Discontinuing Venom Immunotherapy: Reported Studies and Criteria


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Discontinuing Venom Immunotherapy Criteria(Lerch and Muller 1998)

N Systemic P

(pts/stings) Reaction (%)

VIT Duration

<50 months 118 pts 21 (18%)

>50 months 82 pts 4 (5%) 0.007

Insect

Honeybee 120 pts 19 (15.6%)

Vespid 80 pts 6 (7.5%) 0.08

Time since D/C VIT

1-2 years 444 stings 20 (4.5%)

3-5 years 211 stings 30 (14%) 0.001

6-7 years 64 stings 5 (8%)


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Discontinuing Venom Immunotherapy Criteria(Golden et al JACI 2000)

Systemic reaction

Venom Skin Test Positive 10% / sting

Venom Skin Test Negative 10% / sting

Off VIT 3 yrs (1 - 4 yrs) 10% / sting

Off VIT 10 yrs (5 - 13 yrs) 10% / sting

Cumulative risk (10 yrs) 17%


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COLLABORATORS Criteria

Lawrence M. Lichtenstein

Anne Kagey-Sobotka

Robert G. Hamilton

Philip S. Norman

Timothy J. Craig

Denise C. Kelly

Kristin Chichester

Tina D. Grace

General Clinical Research Center (GCRC):

Johns Hopkins Bayview, Baltimore, MD

Penn State University, Hershey, PA

Funding: NIH AI08270 (L. M. Lichtenstein, P.I.)


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