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Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management

Theodore Freeman, MD
Section Editor
David B Golden, MD
Deputy Editor
Anna M Feldweg, MD


Hymenoptera species that sting humans include bees, wasps, yellow jackets, hornets, and imported fire ants. Most people develop only minor local reactions, but patients with venom allergy are at risk for systemic allergic reactions (ie, anaphylaxis), which can be particularly severe and are a leading cause of anaphylaxis fatalities. There are also several uncommon and delayed types of reactions that may develop after Hymenoptera stings, such as serum sickness.

This topic reviews the types of reactions that result from Hymenoptera stings, including local reactions and systemic allergic reactions, and the acute management of each. The diagnosis and long-term management of Hymenoptera allergy are presented separately. (See "Diagnosis of Hymenoptera venom allergy" and "Hymenoptera venom immunotherapy: Efficacy, indications, and mechanism of action".)


The insects that are responsible for the majority of serious sting-related reactions belong to the order Hymenoptera. The Hymenoptera families of medical interest include the following [1-3]:

The winged Hymenoptera:

Apidae family (honey bees (picture 1) and bumble bees).

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Literature review current through: Nov 2017. | This topic last updated: Dec 12, 2017.
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  1. Gurlanick MW, Benton AW. Entomological aspects of insect sting allergy. In: Monograph on insect allergy, 4th ed, Levine MI, Lockey RF (Eds), Dave Lambert Associates, Pittsburgh 2003. p.11.
  2. Goddard J. Physician's guide to arthropods of medical importance, 4th ed, CRC Press, Boca Raton 2003.
  3. Brown SG, Wiese MD, Blackman KE, Heddle RJ. Ant venom immunotherapy: a double-blind, placebo-controlled, crossover trial. Lancet 2003; 361:1001.
  4. Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet 1996; 348:301.
  5. Jain V, Shome D, Natarajan S. Corneal bee sting misdiagnosed as viral keratitis. Cornea 2007; 26:1277.
  6. Hur W, Ahn SK, Lee SH, Kang WH. Cutaneous reaction induced by retained bee stinger. J Dermatol 1991; 18:736.
  7. Tracy JM, Demain JG, Quinn JM, et al. The natural history of exposure to the imported fire ant (Solenopsis invicta). J Allergy Clin Immunol 1995; 95:824.
  8. Triplett RF. The imported fire ant: health hazard or nuisance? South Med J 1976; 69:258.
  9. Severino M, Bonadonna P, Passalacqua G. Large local reactions from stinging insects: from epidemiology to management. Curr Opin Allergy Clin Immunol 2009; 9:334.
  10. Golden DB, Demain J, Freeman T, et al. Stinging insect hypersensitivity: A practice parameter update 2016. Ann Allergy Asthma Immunol 2017; 118:28.
  11. Reisman RE. Clinical aspects of Hymenoptera allergy. In: Monograph on insect allergy, 4th ed, Levine MI, Lockey RF (Eds), Dave Lambert Associates, Pittsburgh 2003. p.55.
  12. Mauriello PM, Barde SH, Georgitis JW, Reisman RE. Natural history of large local reactions from stinging insects. J Allergy Clin Immunol 1984; 74:494.
  13. Graft DF, Schuberth KC, Kagey-Sobotka A, et al. A prospective study of the natural history of large local reactions after Hymenoptera stings in children. J Pediatr 1984; 104:664.
  14. Freeman TM. Clinical practice. Hypersensitivity to hymenoptera stings. N Engl J Med 2004; 351:1978.
  15. Oude Elberink JN, De Monchy JG, Van Der Heide S, et al. Venom immunotherapy improves health-related quality of life in patients allergic to yellow jacket venom. J Allergy Clin Immunol 2002; 110:174.
  16. deShazo RD, Griffing C, Kwan TH, et al. Dermal hypersensitivity reactions to imported fire ants. J Allergy Clin Immunol 1984; 74:841.
  17. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
  18. Tang ML, Osborne N, Allen K. Epidemiology of anaphylaxis. Curr Opin Allergy Clin Immunol 2009; 9:351.
  19. Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978; 299:157.
  20. Smith PL, Kagey-Sobotka A, Bleecker ER, et al. Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66:1072.
  21. Graif Y, Romano-Zelekha O, Livne I, et al. Allergic reactions to insect stings: results from a national survey of 10,000 junior high school children in Israel. J Allergy Clin Immunol 2006; 117:1435.
  22. Golden DB. Insect sting anaphylaxis. Immunol Allergy Clin North Am 2007; 27:261.
  23. Bilò BM, Bonifazi F. Epidemiology of insect-venom anaphylaxis. Curr Opin Allergy Clin Immunol 2008; 8:330.
  24. Graft DF. Insect sting allergy. Med Clin North Am 2006; 90:211.
  25. Valentine MD, Schuberth KC, Kagey-Sobotka A, et al. The value of immunotherapy with venom in children with allergy to insect stings. N Engl J Med 1990; 323:1601.
  26. Barnard JH. Studies of 400 Hymenoptera sting deaths in the United States. J Allergy Clin Immunol 1973; 52:259.
  27. Schwartz HJ, Squillace DL, Sher TH, et al. Studies in stinging insect hypersensitivity: postmortem demonstration of antivenom IgE antibody in possible sting-related sudden death. Am J Clin Pathol 1986; 85:607.
  28. Riches KJ, Gillis D, James RA. An autopsy approach to bee sting-related deaths. Pathology 2002; 34:257.
  29. Golden DB, Marsh DG, Kagey-Sobotka A, et al. Epidemiology of insect venom sensitivity. JAMA 1989; 262:240.
  30. Levine MI, Nall TM. Pathologic findings in Hymenoptera sting fatalities. In: Monograph on insect allergy, 4th ed, Levine MI, Lockey RF (Eds), Dave Lambert Associates, Pittsburgh 2003. p.83.
  31. Müller UR. Bee venom allergy in beekeepers and their family members. Curr Opin Allergy Clin Immunol 2005; 5:343.
  32. Mueller UR. Cardiovascular disease and anaphylaxis. Curr Opin Allergy Clin Immunol 2007; 7:337.
  33. Toogood JH. Risk of anaphylaxis in patients receiving beta-blocker drugs. J Allergy Clin Immunol 1988; 81:1.
  34. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30:1144.
  35. Akin C, Scott LM, Kocabas CN, et al. Demonstration of an aberrant mast-cell population with clonal markers in a subset of patients with "idiopathic" anaphylaxis. Blood 2007; 110:2331.
  36. Haeberli G, Brönnimann M, Hunziker T, Müller U. Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Clin Exp Allergy 2003; 33:1216.
  37. Ludolph-Hauser D, Ruëff F, Fries C, et al. Constitutively raised serum concentrations of mast-cell tryptase and severe anaphylactic reactions to Hymenoptera stings. Lancet 2001; 357:361.
  38. Golden DBK. Insect allergy. In: Middleton's allergy: Principles and practice, 8th ed, Adkinson NF, Bochner B, Busse WW, et al (Eds), Elsevier (Saunders), Philadelphia 2014. p.1260.
  39. Stoevesandt J, Hain J, Kerstan A, Trautmann A. Over- and underestimated parameters in severe Hymenoptera venom-induced anaphylaxis: cardiovascular medication and absence of urticaria/angioedema. J Allergy Clin Immunol 2012; 130:698.
  40. Reisman RE. Natural history of insect sting allergy: relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactions. J Allergy Clin Immunol 1992; 90:335.
  41. Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999; 170:223.
  42. Betten DP, Richardson WH, Tong TC, Clark RF. Massive honey bee envenomation-induced rhabdomyolysis in an adolescent. Pediatrics 2006; 117:231.
  43. Allsopp M. The Pretoria Killer Bee. Am Bee J 1992; 132:516.
  44. Moffitt JE. Allergic reactions to insect stings and bites. South Med J 2003; 96:1073.
  45. Pinto MA, Rubink WL, Patton JC, et al. Africanization in the United States: replacement of feral European honeybees (Apis mellifera L.) by an African hybrid swarm. Genetics 2005; 170:1653.
  46. Reisman RE, Livingston A. Late-onset allergic reactions, including serum sickness, after insect stings. J Allergy Clin Immunol 1989; 84:331.
  47. Reisman RE. Unusual reactions to insect stings. Curr Opin Allergy Clin Immunol 2005; 5:355.
  48. Quercia O, Emiliani F, Foschi FG, Stefanini GF. Unusual reaction to hymenoptera sting: a case of Schönlein-Henoch purpura. Allergy 2007; 62:333.
  49. Lichtenstein LM, Golden DB. Postscript to bee stings: delayed 'serum sickness'. Hosp Pract (Off Ed) 1983; 18:36, 40, 40A, passim.
  50. Hogendijk S, Hauser C. Wasp sting-associated cold urticaria. Allergy 1997; 52:1145.
  51. Kalogeromitros D, Gregoriou S, Papaioannou D, et al. Acquired primary cold contact urticaria after Hymenoptera sting. Clin Exp Dermatol 2004; 29:93.
  52. Wong CG, Borici-Mazi R. Delayed-onset cold anaphylaxis after hymenoptera sting. Ann Allergy Asthma Immunol 2012; 109:77.