Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Diagnosis of Hymenoptera venom allergy

INTRODUCTION AND TERMINOLOGY

The majority of serious sting-related reactions are caused by insects belonging to the order Hymenoptera. Within this order, three families are medically important:

The diagnosis of Hymenoptera allergy (except ants), which is based upon the clinical history and testing for the presence of venom-specific IgE antibodies, will be reviewed here. Accurate diagnosis of venom allergy is important because patients with venom allergy are candidates for venom immunotherapy, a treatment which can dramatically reduce the risk of recurrent severe reactions [1]. The indications and protocols for venom immunotherapy are presented separately. (See "Hymenoptera venom immunotherapy: Efficacy, indications, and mechanism of action" and "Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring".)

TYPES OF REACTIONS

Most people develop only minor local reactions to Hymenoptera stings. A local reaction is defined as any reaction in which the signs and symptoms are confined to tissues contiguous with the sting site. These reactions are described in detail separately. (See "Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management", section on 'Local reactions'.)

In contrast, systemic reactions cause signs and symptoms throughout the body and include a spectrum of manifestations, ranging from mild to life-threatening. Mild systemic reactions may be limited to the skin and consist of flushing, urticaria, and angioedema. More severe systemic reactions (ie, anaphylaxis) can involve bronchospasm, laryngeal edema, and hypotension. Venom-induced anaphylaxis can be particularly severe and is a leading cause of fatal anaphylaxis. Systemic reactions are described in detail elsewhere. (See "Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management", section on 'Systemic allergic reactions/anaphylaxis' and "Fatal anaphylaxis".)

                         

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: Apr 2013. | This topic last updated: Sep 20, 2012.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. Franken HH, Dubois AE, Minkema HJ, et al. Lack of reproducibility of a single negative sting challenge response in the assessment of anaphylactic risk in patients with suspected yellow jacket hypersensitivity. J Allergy Clin Immunol 1994; 93:431.
  2. Freeman TM. Clinical practice. Hypersensitivity to hymenoptera stings. N Engl J Med 2004; 351:1978.
  3. Golden DB, Marsh DG, Kagey-Sobotka A, et al. Epidemiology of insect venom sensitivity. JAMA 1989; 262:240.
  4. Golden DB, Breisch NL, Hamilton RG, et al. Clinical and entomological factors influence the outcome of sting challenge studies. J Allergy Clin Immunol 2006; 117:670.
  5. Light WC, Reisman RE, Shimizu M, Arbesman CE. Unusual reactions following insect stings. Clinical features and immunologic analysis. J Allergy Clin Immunol 1977; 59:391.
  6. Reisman RE. Unusual reactions to insect stings. Curr Opin Allergy Clin Immunol 2005; 5:355.
  7. Goldberg A, Confino-Cohen R. Timing of venom skin tests and IgE determinations after insect sting anaphylaxis. J Allergy Clin Immunol 1997; 100:182.
  8. Mittermann I, Zidarn M, Silar M, et al. Recombinant allergen-based IgE testing to distinguish bee and wasp allergy. J Allergy Clin Immunol 2010; 125:1300.
  9. Hoffman DR, El-Choufani SE, Smith MM, de Groot H. Occupational allergy to bumblebees: allergens of Bombus terrestris. J Allergy Clin Immunol 2001; 108:855.
  10. de Groot H. Allergy to bumblebees. Curr Opin Allergy Clin Immunol 2006; 6:294.
  11. Regularly updated maps of the fire ant range and agriculture quarantine areas within the United States. www.aphis.usda.gov/plant_health/plant_pest_info/fireants/downloads/fireant.pdf (Accessed on September 14, 2010).
  12. Georgitis JW, Reisman RE. Venom skin tests in insect-allergic and insect-nonallergic populations. J Allergy Clin Immunol 1985; 76:803.
  13. Biló BM, Rueff F, Mosbech H, et al. Diagnosis of Hymenoptera venom allergy. Allergy 2005; 60:1339.
  14. Golden DB, Moffitt J, Nicklas RA, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127:852.
  15. Golden DB, Kagey-Sobotka A, Norman PS, et al. Insect sting allergy with negative venom skin test responses. J Allergy Clin Immunol 2001; 107:897.
  16. Golden DB, Marsh DG, Freidhoff LR, et al. Natural history of Hymenoptera venom sensitivity in adults. J Allergy Clin Immunol 1997; 100:760.
  17. Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978; 299:157.
  18. Parker JL, Santrach PJ, Dahlberg MJ, Yunginger JW. Evaluation of Hymenoptera-sting sensitivity with deliberate sting challenges: inadequacy of present diagnostic methods. J Allergy Clin Immunol 1982; 69:200.
  19. Hoffman DR. Allergens in Hymenoptera venom. XXV: The amino acid sequences of antigen 5 molecules and the structural basis of antigenic cross-reactivity. J Allergy Clin Immunol 1993; 92:707.
  20. King TP, Joslyn A, Kochoumian L. Antigenic cross-reactivity of venom proteins from hornets, wasps, and yellow jackets. J Allergy Clin Immunol 1985; 75:621.
  21. Reisman RE, Mueller U, Wypych J, et al. Comparison of the allergenicity and antigenicity of yellow jacket and hornet venoms. J Allergy Clin Immunol 1982; 69:268.
  22. Reisman RE. Insect sting allergy: the dilemma of the negative skin test reactor. J Allergy Clin Immunol 2001; 107:781.
  23. Niedoszytko M, de Monchy J, van Doormaal JJ, et al. Mastocytosis and insect venom allergy: diagnosis, safety and efficacy of venom immunotherapy. Allergy 2009; 64:1237.
  24. Golden DB, Tracy JM, Freeman TM, et al. Negative venom skin test results in patients with histories of systemic reaction to a sting. J Allergy Clin Immunol 2003; 112:495.
  25. Hamilton RG. Diagnostic methods for insect sting allergy. Curr Opin Allergy Clin Immunol 2004; 4:297.
  26. Eberlein B, Krischan L, Darsow U, et al. Double positivity to bee and wasp venom: improved diagnostic procedure by recombinant allergen-based IgE testing and basophil activation test including data about cross-reactive carbohydrate determinants. J Allergy Clin Immunol 2012; 130:155.
  27. Korošec P, Valenta R, Mittermann I, et al. High sensitivity of CAP-FEIA rVes v 5 and rVes v 1 for diagnosis of Vespula venom allergy. J Allergy Clin Immunol 2012; 129:1406.
  28. Korošec P, Valenta R, Mittermann I, et al. Low sensitivity of commercially available rApi m 1 for diagnosis of honeybee venom allergy. J Allergy Clin Immunol 2011; 128:671.
  29. Hamilton RG. Responsibility for quality IgE antibody results rests ultimately with the referring physician. Ann Allergy Asthma Immunol 2001; 86:353.
  30. González de Olano D, Alvarez-Twose I, Esteban-López MI, et al. Safety and effectiveness of immunotherapy in patients with indolent systemic mastocytosis presenting with Hymenoptera venom anaphylaxis. J Allergy Clin Immunol 2008; 121:519.
  31. Brockow K, Jofer C, Behrendt H, Ring J. Anaphylaxis in patients with mastocytosis: a study on history, clinical features and risk factors in 120 patients. Allergy 2008; 63:226.
  32. Ruëff F, Przybilla B, Biló MB, et al. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol 2009; 124:1047.
  33. Bonadonna P, Zanotti R, Müller U. Mastocytosis and insect venom allergy. Curr Opin Allergy Clin Immunol 2010; 10:347.
  34. 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.
  35. 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.
  36. Müller UR. Elevated baseline serum tryptase, mastocytosis and anaphylaxis. Clin Exp Allergy 2009; 39:620.
  37. Kosnik M, Korosec P. Importance of basophil activation testing in insect venom allergy. Allergy Asthma Clin Immunol 2009; 5:11.
  38. Korosec P, Erzen R, Silar M, et al. Basophil responsiveness in patients with insect sting allergies and negative venom-specific immunoglobulin E and skin prick test results. Clin Exp Allergy 2009; 39:1730.
  39. Peternelj A, Silar M, Bajrovic N, et al. Diagnostic value of the basophil activation test in evaluating Hymenoptera venom sensitization. Wien Klin Wochenschr 2009; 121:344.
  40. van der Linden PW, Hack CE, Struyvenberg A, van der Zwan JK. Insect-sting challenge in 324 subjects with a previous anaphylactic reaction: current criteria for insect-venom hypersensitivity do not predict the occurrence and the severity of anaphylaxis. J Allergy Clin Immunol 1994; 94:151.
  41. 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.
  42. Mauriello PM, Barde SH, Georgitis JW, Reisman RE. Natural history of large local reactions from stinging insects. J Allergy Clin Immunol 1984; 74:494.
  43. Golden DB, Kelly D, Hamilton RG, Craig TJ. Venom immunotherapy reduces large local reactions to insect stings. J Allergy Clin Immunol 2009; 123:1371.
  44. Walker R, Jacobs J, Tankersley M, et al. Rush immunotherapy for the prevention of large local reactions secondary to imported fire ant stings. J Allergy Clin Immunol 1999; 103:S180 (Abstract).