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By: Dr Ismah
1
0
1
2
3
4
5
6
Bee Centipide Scorpion
6 (75%)
1 1
Total: 8/101 cases
2
3
The 18-year-old from Des
Moines, Iowa, was stung for the
first time when she was only
4 when a bee sting on
her neck mad...
1. History
2. Epidemiology
3. Bee?
4. Pathogenesis
5. Diagnosis
6. Management
7. Anaphylaxis
8. Prevention
4
• The first reports of stinging insect
allergy came from the Middle East
thousands of years ago
5
• 56.6 – 94.5% stung by Hymenoptera insect
at least once in live
• Fatal stings at least 40 cases each year in
USA and 16–...
• Systemic allergic reactions up to 3% of
adults and 1% of children.
• In children about 60 % of systemic sting
reactions ...
• The name Hymenoptera is derived from
the Greek words "hymen" meaning
membrane and "ptera" meaning wings
8
9
10
11
12
13
• Honey bees are only capable of stinging a
person once.
• The honey bee is the only stinging insect that
leaves its sting...
15
• Bumblebees rarely sting people because they
are non-aggressive and typically well
mannered
• They generally will sting o...
• Wasps build honey-comb nests under the
eaves of a house, or in a tree, shrub or
under furniture.
• They tend to be less ...
• They tend to be very aggressive insects,
and will often sting without provocation.
• They are commonly found around garb...
• These insects may be very aggressive,
and a sting may be provoked by a minor
disruption in their environment.
• Hornets ...
• Bees release large amount of venom,
average 50–140 mcg/sting.
• Allergens constituting the venom include
• vasoactive am...
• Venom sacs may contain up to more than 300
mcg of venom
• Wasp, which are capable of repeated stings,
generally inject l...
22
Allergic responses to
stinging
1. Localized cutaneous reactions
2. Systemic anaphylaxis
• Localized skin responses to biting insects
are caused primarily by vasoactive or irritant
materials derived from insect ...
• History
• Clinical manifestation
• Investigation
24
Categorie
s
Local
Large
local
Generalized
cutaneous
Systemic
Toxic
Delayed
/late
25
• Local: Insect bites are usually urticarial but may
be papular or vesicular, limited swelling <24 hrs
• Large local: an a...
27
Generalized cutaneous reactions
• Typically progress within minutes and
include cutaneous symptoms of:
i. Urticaria
ii. An...
29
30
31
• Rhabdomyolysis, acute renal failure, Guillain-
Barré syndrome, myasthenia gravis and
coagulopathy following multiple bee...
• Toxic reaction: in mass bee envenomation due to the
direct action of large amount of venom, not due to allergic
reaction...
• Delayed/late
i. Nephrotic syndrome
ii. Vasculitis
iii. Neuritis
iv. Encephalopathy
34
“Rarely a biphasic course is obser...
35
• Blood test
• UFEME
• Prink skin testing, to identify venom
specific IgE
36
37
• Stingers should be removed promptly by
scraping, with caution not to squeeze the venom
sac because doing so could inject...
• Hymenoptera VIT is highly effective (95-97%) in
decreasing the risk for severe anaphylaxis.
• The selection of patients ...
40
SYMPTOMS AGE
SKIN TEST/IN VITRO
TEST
RISK OF
SYSTEMIC
REACTION IF
UNTREATED
(%)
VIT
RECOMMENDE
D
Large local
reaction
A...
41
• Anaphylaxis is a severe, life threatening,
generalised or systemic hypersensitivity reaction.
• It is characterized by r...
Airways
problem
Breathing
problems
Circulation
problems
43
• Airway swelling
• Hoarse voice
• Stridor
• Dyspnoea
• Wheeze
...
• Previous severe reaction.
• History of increasingly severe reaction.
• History of asthma.
44
• Therapies may include:
i. Oxygen
ii. Epinephrine
iii. Intravenous saline
iv. Steroids
v. Antihistamines
45
46
47
48
*If hypotensive persist despite adequate fluid (CVP>10),
obtain echocardiogram and consider infusing noradrenaline
as w...
• Oral prednisolone 1m/kg can be used in milder
case.
• Antihistamine are effective in relieving cutaneous
symptoms but ma...
• Prevention of further episodes.
• Education of patients and caregivers in the early
recognition and treatment of allergi...
51
• Frequent cleaning of surroundings, garbage cans
and decaying fruit makes it less attractive for
bees.
• Cracks in ceilin...
53
• While rescuing a victim of massive bee sting,
protective gear should be worn. Remove the
victim to a safe area, remove t...
• History of exposure
+Types of bees
• Clinical course
• Anaphylaxis
• Management
• Prevention
55
1. Pediatric protocol 3rd ed
2. Insect Allergy by Prof. Dr. Saad S Al Ani, Senior Pediatric
Consultant, Khorfakkan hospita...
57
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Insect bites

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Insect bites

  1. 1. By: Dr Ismah 1
  2. 2. 0 1 2 3 4 5 6 Bee Centipide Scorpion 6 (75%) 1 1 Total: 8/101 cases 2
  3. 3. 3 The 18-year-old from Des Moines, Iowa, was stung for the first time when she was only 4 when a bee sting on her neck made it swell to the size of a "balloon."
  4. 4. 1. History 2. Epidemiology 3. Bee? 4. Pathogenesis 5. Diagnosis 6. Management 7. Anaphylaxis 8. Prevention 4
  5. 5. • The first reports of stinging insect allergy came from the Middle East thousands of years ago 5
  6. 6. • 56.6 – 94.5% stung by Hymenoptera insect at least once in live • Fatal stings at least 40 cases each year in USA and 16–38 cases in France. 6
  7. 7. • Systemic allergic reactions up to 3% of adults and 1% of children. • In children about 60 % of systemic sting reactions are mild, whereas in adults respiratory or cardiovascular symptoms occur in about 70 %. • Children also have a better prognosis than adults with respect to the risk of systemic reactions to re-stings. 7
  8. 8. • The name Hymenoptera is derived from the Greek words "hymen" meaning membrane and "ptera" meaning wings 8
  9. 9. 9
  10. 10. 10
  11. 11. 11
  12. 12. 12
  13. 13. 13
  14. 14. • Honey bees are only capable of stinging a person once. • The honey bee is the only stinging insect that leaves its stinger and venom sac in the skin of its victim, due to the pointed configuration of the stinger. 14
  15. 15. 15
  16. 16. • Bumblebees rarely sting people because they are non-aggressive and typically well mannered • They generally will sting only if provoked • They nest in the ground or in piles of grass clippings or wood 16
  17. 17. • Wasps build honey-comb nests under the eaves of a house, or in a tree, shrub or under furniture. • They tend to be less aggressive than yellow jackets and hornets, and mostly feed on insects and flower nectar. 17
  18. 18. • They tend to be very aggressive insects, and will often sting without provocation. • They are commonly found around garbage cans and picnic areas where food and sugary drinks are abundant 18
  19. 19. • These insects may be very aggressive, and a sting may be provoked by a minor disruption in their environment. • Hornets look very much like yellow jackets and can be difficult to distinguish 19
  20. 20. • Bees release large amount of venom, average 50–140 mcg/sting. • Allergens constituting the venom include • vasoactive amines, • small polypeptides and enzymes, • histamine, mast cell degranulating peptide, • phospholipase A2 (PLA2), hyaluronidase, • acid phosphatase and melittin 20
  21. 21. • Venom sacs may contain up to more than 300 mcg of venom • Wasp, which are capable of repeated stings, generally inject less venom per sting 21 • 10 to 31 mcg of venom/sting Bumble bees • 1.7 to 3.1 mcg of venom/sting Wasp • 2.4 to 5.0 mcg of venom/sting Yellow jacket wasp
  22. 22. 22 Allergic responses to stinging 1. Localized cutaneous reactions 2. Systemic anaphylaxis
  23. 23. • Localized skin responses to biting insects are caused primarily by vasoactive or irritant materials derived from insect saliva, and rarely occur from IgE-associated responses • The majority of patients who experience systemic reactions after Hymenoptera stings have IgE-mediated sensitivity to antigenic substances in the venom. 23
  24. 24. • History • Clinical manifestation • Investigation 24
  25. 25. Categorie s Local Large local Generalized cutaneous Systemic Toxic Delayed /late 25
  26. 26. • Local: Insect bites are usually urticarial but may be papular or vesicular, limited swelling <24 hrs • Large local: an area of induration with a diameter of 10 cm or more; which peaks between 24 hours and 48 hours and then subsides, may last for days 26
  27. 27. 27
  28. 28. Generalized cutaneous reactions • Typically progress within minutes and include cutaneous symptoms of: i. Urticaria ii. Angioedema iii. Pruritus *beyond the site of the sting 28
  29. 29. 29
  30. 30. 30
  31. 31. 31
  32. 32. • Rhabdomyolysis, acute renal failure, Guillain- Barré syndrome, myasthenia gravis and coagulopathy following multiple bee stings. • Acute kidney injury (AKI) was seen in 21.0% patients. Rhabdomyolysis was seen in 24.1% patients, hemolysis in 19.2% patients, liver injury in 30.1% patients, and coagulopathy in 22.5% patients 7 • High creatinine level, shock, oliguria, and anemia were risk factors for death 7 32
  33. 33. • Toxic reaction: in mass bee envenomation due to the direct action of large amount of venom, not due to allergic reaction i. Fever ii. Malaise iii. Vomiting iv. Nausea *due to the chemical properties of the venom in large doses. In younger children less than 50 stings may prove lethal Forty-eight patients died of organ injury following toxic reactions to the stings, whereas six died from anaphylactic shock from total of 1091 patients hospitalized 7 33
  34. 34. • Delayed/late i. Nephrotic syndrome ii. Vasculitis iii. Neuritis iv. Encephalopathy 34 “Rarely a biphasic course is observed with an early onset, an apparent recovery and a subsequent relapse after 4-24 hours”
  35. 35. 35
  36. 36. • Blood test • UFEME • Prink skin testing, to identify venom specific IgE 36
  37. 37. 37
  38. 38. • Stingers should be removed promptly by scraping, with caution not to squeeze the venom sac because doing so could inject more venom 38
  39. 39. • Hymenoptera VIT is highly effective (95-97%) in decreasing the risk for severe anaphylaxis. • The selection of patients for VIT depends on several factors • Price? injection immunotherapy is less expensive than sublingual immunotherapy with the cost per kit of approximately $150 and about 3 or 4 kits required over the time of the immunotherapy. Sublingual treatment is between $500 and $1000 per year 39
  40. 40. 40 SYMPTOMS AGE SKIN TEST/IN VITRO TEST RISK OF SYSTEMIC REACTION IF UNTREATED (%) VIT RECOMMENDE D Large local reaction Any Usually not indicated 4-10 Usually not indicated Generalized cutaneous reaction ≤16 yr Usually not indicated 9-10 Usually not indicated ≥17 yr Positive result 20 Yes Negative result — No Systemic reaction Any Positive result Child: 40 Adult: 60-70 Yes Negative result — Usually no
  41. 41. 41
  42. 42. • Anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction. • It is characterized by rapidly (minutes to hours) developing life threatening airway and/or breathing and /or circulation problems usually associated with skin and/ or mucosa changes. 42
  43. 43. Airways problem Breathing problems Circulation problems 43 • Airway swelling • Hoarse voice • Stridor • Dyspnoea • Wheeze • Hypoxia leading to confusion • Cyanosis • Respirator y arrest • Shock • Faintness • Palpitation s • Cardiac arrest
  44. 44. • Previous severe reaction. • History of increasingly severe reaction. • History of asthma. 44
  45. 45. • Therapies may include: i. Oxygen ii. Epinephrine iii. Intravenous saline iv. Steroids v. Antihistamines 45
  46. 46. 46
  47. 47. 47
  48. 48. 48 *If hypotensive persist despite adequate fluid (CVP>10), obtain echocardiogram and consider infusing noradrenaline as well as adrenaline. ** Dose of intravenous corticosteroid should be equivalent to 1-2mg/kg/dose of methylprednisolone every 6 hours (prevent biphasic reaction).
  49. 49. • Oral prednisolone 1m/kg can be used in milder case. • Antihistamine are effective in relieving cutaneous symptoms but may cause drowsiness and hypotension. • Continue observation for 6-24 hours depending on severity of reaction because of the risk of biphasic reaction and the wearing off of adrenaline dose. 49
  50. 50. • Prevention of further episodes. • Education of patients and caregivers in the early recognition and treatment of allergic reaction. • An adrenaline auto injector should be prescribed for those with history of severe reaction to food, latex, insect sting, exercise and idiopathic anaphylaxis and with risk factor like asthma. 50
  51. 51. 51
  52. 52. • Frequent cleaning of surroundings, garbage cans and decaying fruit makes it less attractive for bees. • Cracks in ceilings and walls should be sealed off as they are potential nesting sites for colonies • Best defence, when attacked by bees, is to run to a place which can be sealed off, leaving the bees outside 52
  53. 53. 53
  54. 54. • While rescuing a victim of massive bee sting, protective gear should be worn. Remove the victim to a safe area, remove the stinger and shift to hospital • To kill bees, 1–3% foam or detergent water mixture can be sprayed on the swarm of attacking bees. • Insecticide should be sprayed around the nests at night, when they are less active 54
  55. 55. • History of exposure +Types of bees • Clinical course • Anaphylaxis • Management • Prevention 55
  56. 56. 1. Pediatric protocol 3rd ed 2. Insect Allergy by Prof. Dr. Saad S Al Ani, Senior Pediatric Consultant, Khorfakkan hospital Sharjah, UAE 3. Allergy: Principles and Practice by Lieberman P, Elsevier Inc, 2009 4. General entomology, http://www.cals.ncsu.edu 5. Indian Guidelines and Protocols: Bee Sting 6. Diagnosis Of Hymenoptera Venom Allergy, Eaaci Position Paper 7. Xie C, Xu S, Ding F, Xie M, Lv J, et al. (2013) Clinical Features of Severe Wasp Sting Patients with Dominantly Toxic Reaction: Analysis of 1091 Cases. PLoS ONE 8(12): e83164. doi:10.1371/journal.pone.0083164 56
  57. 57. 57
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