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Insect allergy

Insect allergy. Joanna Lange. Epidemiology. 0,4 % of the population in the USA; c ross - sectional studies : 1 - 3% prevalence of systemic reaction ; 9 - 32% sensitization to insect venoms; d eaths to Hymenoptera stings – 40/per year in the USA;. Taxonomy of Hymenoptera.

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Insect allergy

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  1. Insect allergy Joanna Lange

  2. Epidemiology • 0,4 % of the population in the USA; • cross-sectional studies: • 1-3% prevalence of systemic reaction; • 9-32% sensitization to insect venoms; • deaths to Hymenoptera stings – 40/per year in the USA;

  3. Taxonomy of Hymenoptera

  4. Vespa crabro – European hornet Vespula rufa Paravespula germanica Vespa orientalis

  5. Dolichovespula adulteriana Polistes gallicus Dolichovespula media Polistes nimpha

  6. A cluster of honeybee.

  7. Paper wasp Papernet wasp

  8. In central and northernEurope vespid (mainly Vespula spp.) and honeybee stings are the most prevalent. In the Mediterranean area stings from Polistes and Vespula are more frequent than honeybee stings. The stinger of honeybees usually remains in human skin. Bumblee-bees and vespids normally remove their stinger from the human skin.

  9. Cross - reactivite among Hymenoptera APIDAE APIS BOMBUS VESPULA DOLICHOVESPULA VESPACRABRO VESPIDAE POLISTES VESPAORIENTALIS

  10. Venom biochemistry

  11. Venom biochemistry • all venom allergens are proteins, and most are enzymes with molecular weights between 13,000 to 50,000D; • with the exeption of mellitin from honeybee venom, the peptides of Hymenoptera venoms are nonallergic but are responsible for the toxic and pharmacologies acitvities of venom; • in addition to the proteins and peptides, Hymenoptera venoms contain vasoactive amines, such as – histamine, 5-hydroxytryptamine, acetylocholine, dopamine and norepinephrine

  12. Venom biochemistry • within the yellow jacket family there is strong cross - antigenicity and cross –allergenicity among venoms from V. maculifrons, V.germanica, V.vulgaris and V.flavopilosa; • similar findings have been reported for the paper wasp family; • there are rare individuals who react only to venom from one vespid species; • there is little or no cross – reactivity between honeybee venom phospholipase A and vespid venom phospholipase A, whereas hyaluronidase from bee and vespid venom may cross - react.

  13. Bee venom Venom biochemistry Substances of lower molecular weight: feromones, histamin -local toxity, dopamin, norepinephrine, aminoacides, oligopeptides, fosfolipids, węglowodany; Bigger peptides -1000-5000: mellitin – membrane poisson; apamin - neurotoxin; Peptide - MCD, tertiapine - liberator of histamin; secapine; kardiopeptide – positive inotropic and chronotropic; Enzymes - 10000 do 200000: phospholipase A2 - membrane poisson – very high alergogenity; hyaluronidase – high alergogenity; acid phosphatase; alfa-glukosidase; esterases; Another: adolapin – pain relief, alergen C;

  14. Bombus venom Venom biochemistry phospholipasa A2; hialuronidase; acid phosphatase; Immunological mimikra to bee venom

  15. Vespa venom Venom biochemistry • histamin – higher than bee venom; • serotonin; • acetylocholin; • kinines; • mastoparan – degranulates mast cells; • hemolizyn - mellitin – like; • phospholipase A i B; • hialuronidases; • antigen 5; Allergens activity - phospholipases, hialuronidase i antigen 5;

  16. Clinical presentation and pathogenesis of sting reactions

  17. Clinical presentation • venom hypersensitivity may be mediated by immunologic mechanisms (IgE or not-IgE), but also by non - immunological mechanisms; • classification if the reaction: • normal local reaction; • large local reaction; • systemic toxic reaction; • systemic anaphzlactic reaction; • unusual reaction.

  18. Clinical presentation Normal local sting reaction • local reaction with pain; • erythema; • slight swelling around the sting side; • subside within 24 hours; • only a small sting reaction may be remain a visible for a few days.

  19. Clinical presentation Large local sting reaction(LLR) • swelling exceeding a diameter of 10 cm last longer than 24 hours; • blisters may be rarely present; • sometimes swollen lymph glands; • great discomfortwhen symptoms prolonged few days;

  20. Clinical presentation Systemic anaphylactic reaction • most often IgE - mediated; • non - IgE mediated reaction - due to short term sensitising IgG or complement activation by IgG-venom complexes; • most often symptoms appear within few minutes after the sting; • recovering few hours after stinging;

  21. Classification of systemic reaction to insect sting by H.L. Mueller

  22. Classification of systemic reaction modifide according to J. Ring and Messmer

  23. Clinical presentation Systemic toxic reaction • toxic effect – phospholipase and hyaluronidase; • after multiple – usually 50 -100 stings; • symptoms:rhabdomyolisis, myocardial damage, hepatic dysfunction, intravascular haemolysis, acute renal failure, coagulation disorders with bleeding and DIC;

  24. Clinical presentation Unusual reaction • serum sikness like symptoms with fever, arthralgias, urticaria, angioedema, lymphadenopathy and neurological symptoms; • gromeluronephritis, acute allergic renal nephritis, haemolytic anemia, thrombocytopenia, myocarditis, Guillain-Barre sydrome

  25. Diagnosis • history; • skin tests; • in vitro tests; • allergen specific IgG; • baseline serum tryptase; • other in vitro tests

  26. Diagnostic tests should be done in all patients with a history of a systemic sting reaction to detect sensitisation; • Diagnostic tests are not recommended in subjects with a history of large local reaction or no history of a systemic reaction; • Testing comprises skin tests with Hymenophtera venoms and analysis of the serum for Hymenophtera venom-specific IgE; • Stepwise skin testing with incremental venom concentrations is recommended;

  27. If skin prick tests are negative subsequently intradermal tests should be done; • If diagnostic tests are negative they should be repeated several weeks later; • If both skin tests and specific Ige stay negative additional in-vitro tests should be carried out; • Serum tryptase should be analysed in patients with a history of a severe sting reaction

  28. Prevention

  29. Preventing insect stings and bites • Avoid provoking insects whenever possible. • Avoid rapid, jerky movements around insect hives or nests. • Avoid perfumes and floral-patterned or dark clothing. • Use appropriate insect repellants and/or protective clothing. • Use caution when eating outdoors, especially with sweetened beverages or in areas around garbage cans which often attract bees.

  30. Examples of activities implying special risk for stings during warm season • outdoor eating and drinking; • barefoot walking; • gardening (especially cutting hedges, flowers); • picking fruit; • outdoor sporting (especially with scanty outfit or open mouth); • staying close to beehives when honey is collected; • removing vespid nests from attic or windows;

  31. Yellow jacket and Vespa crabro nest

  32. Emergency treatment

  33. Technic of proper removing of the stinger YES YES NO Removing of the stinger

  34. First aid for minor reactions • If the sting is from a honey bee, remove the stinger from the skin if it is still present. Carefully scrape the back of a knife or other thin straight- edged object across the stinger if the victim can remain still, and it is safe to do so. Otherwise, you can pull out the stinger with tweezers or your fingers, but avoid pinching the venom sac at the end of the stinger which will cause more venom to be released. • Wash the site thoroughly with soap and water. • Cover the site with a clean, cold compress or a clean, moist dressing to reduce swelling and discomfort. • Over the next 24 to 48 hours, observe the site for signs of infection (such as increasing redness, swelling, pain). • Sores from scratching can become infected. Keep bites clean and, to prevent infection, don't scratch.

  35. First aid for serious reactions If the victim is having a severe reaction or the victim has been stung inside the mouth or throat, call immediately for emergency medical assistance. • Check the victim’s airway, breathing, and circulation. If necessary, begin rescue breathing and CPR. • Reassure the victim. Try to keep him or her calm, as anxiety will worsen the situation. • Remove nearby rings and constricting items because the affected area may swell. • Use a special allergy first aid kit, if available. (Some people who have serious insect reactions carry it with them.) • If appropriate, treat the victim for signs of shock. Remain with the victim until medical help arrives.

  36. Treatment of systemic reaction to Hymenoptera sting

  37. Treatment of systemic reaction to Hymenoptera sting

  38. Treatment of systemic reaction to Hymenoptera sting

  39. Epinephrine - indications • all with history of anaphylaxis or „ very sensitized”; • those with hymenophtera allergy; • with food allergy; • in patients with anaphylaxis induced by exercises;

  40. Emergency treatment • after a systemic reation, patients should be referred to an allergy specialist for evaluation of their allergy and if necessary VIT; • i.m. epinephrine is regarded as a treatment fo choice for acute anaphylaxis; • H1 – antihistamines alone or in combination with corticosteroids may be efective in mild to moderate, reactions confined to the skin and may support the value of treatment with epinephrine in full-blown anaphylaxis; • untreated patients with a history of a systemic reaction are strongly advised to carry emergency kits containing injectable epinephrine for self administration

  41. Proper using of EpiPen

  42. Remove the device from the plastic protective container. Remove the grey cap from the fatter end of the device. NB: This "arms the unit" ready for use

  43. Hold the EpiPen in your fist with clenched fingers wrapped around it (NB: there is nothing to "push" at the white end) Press the black tip gently against the skin of the mid thigh, then start to push harder until a loud "click" is heard. This means that the device has been activated. Hold in place for 10-15 seconds (count "1 elephant, 2 elephants, 10 elephants etc") while the adrenaline is injected under pressure. NB: The EpiPen "pop" is often quite loud. Remove the pen from the thigh; be careful with the needle that will now be projecting from the EpiPen when you dispose of the device. Massage in the adrenalin. There may be some slight bleeding at the injection site. Apply firm pressure with a cloth, tissue, clean handkerchief or bandage. Record the time that the EpiPen was given. Call for help.

  44. EpiPen Mistakes - what not to do! MISTAKE NUMBER 1 The black tip contains the needle and needs to be placed against the mid-thigh. Holding the wrong end and injecting the thumb (blue line) is painful and not very effective ... MISTAKE NUMBER 2 Unless the grey cap is removed (blue line), the EpiPen will NOT work, no matter how hard you push ...

  45. MISTAKE NUMBER 3 This photograph is more subtle. The patient is pressing the white end very hard (blue line), assuming there is a "button" at the white end. There is not! Unless pressure is exerted at the black end, the EpiPen will not work. By all means rest the thumb on the white end, but you must exert pressure on the black tip into the thigh as well.

  46. First aid kit 30 € 40 € 35 € Epi Mate 35 € www. medicareplus.co.uk

  47. Venom immunotherapy

  48. Venom immunotherapy Indications: • in persons who have expirience a systemic reaction to an insect sting and who have postive skin test (prick or intradermal) at concentration 1 mcg/ml or less; • medical indications are strongest in adults – untreated individuals – 50-60% of risk of systemic reaction if stung again; • large local reactions – only a small risk of anaphylaxix after future stings

  49. Venom immunotherapy Contra indications: • autoimmunologic diseases; • tumors; • immunological deficiences; • children younger than 5 years; • insufficiences of heart, hepatic problems, nephrological problems, epilepsy; • psychiatric problems; • diseases in which adrenalin is conrtaindicated (e.g. pcheochromocytoma, thyreoid tumors);

  50. Indication to the immunotherpy (by Bousquet)in patients above 15 year

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