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."
5. • The first reports of stinging insect
allergy came from the Middle East
thousands of years ago
5
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. • 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. • The name Hymenoptera is derived from
the Greek words "hymen" meaning
membrane and "ptera" meaning wings
8
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
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. • 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. • 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. • 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. • 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. • 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
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
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
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
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. • 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. • 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”
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. • 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
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
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
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. • 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. • 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
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
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. • History of exposure
+Types of bees
• Clinical course
• Anaphylaxis
• Management
• Prevention
55
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
Entomology of bee:
Apidae: brown, hairy
Vespidae: almost hairless, black, yellow stripped
Moderate angioedema
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
Most often symptoms appear within a few minutes to one hour after the sting (6), but rarely they can occur hours or even days later (65). Normally, the patient recovers from anaphylactic reactions within a few hours. Rarely a biphasic course is observed with an early onset, an apparent recovery and a subsequent relapse after 4-24 hours.
