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AND THE ANSWERS ARE . . .

  1. Negative responses to skin tests with an appropriate panel of hymenoptera venoms rules out the likelihood of a systemic reaction to a subsequent HS.
    False
  2. A child with a documented systemic reaction to a HS limited to the skin is unlikely to manifest a more severe systemic reaction to a subsequent repeat HS by the same type of insect.
    True
  3. Immunotherapy with the appropriate hymenoptera venom extract will significantly reduce the likelihood of a severe systemic reaction to a repeat HS in a child who previously had a systemic HS reaction involving multiple organs.
    True
  4. A child with a history of a large local reaction to a HS is at increased risk for a prominent systemic reaction to a repeat HS
    False

Discussion
The large majority of individuals with histories of possible systemic reactions to a HS but then exhibit negative responses to appropriate venom skin testing several months later will not manifest a systemic allergic reaction to a subsequent repeat HS . However, there are a limited number of well-documented cases where systemic reactions have occurred in such skin-test negative individuals (1). Some of these individuals have evidence of IgE anti-venom antibodies in an in vitro RAST or similar test. Likewise, some individuals with such histories have negative venom RAST but positive venom skin tests. Therefore, the Insect Committee of the AAAAI suggests obtaining venom RAST if the venom skin tests are negative in someone with a convincing history for a systemic allergic reaction to a HS (1). Even then, there are a few reported cases where a systemic reaction to a repeat HS occurred in someone with both negative venom skin tests and negative venom RAST.

Studies by a group in the Johns Hopkins Medical Institutions have suggested that children with systemic reactions to HS limited to the skin are not at increased risk for severe systemic reactions to a repeat HS (2). This group recently reported a follow-up questionnaire study of the experience over the next 20+ years of individuals who had been evaluated previously in their childhood because of possible systemic reactions to HS (3). A small minority of those with histories of just cutaneous reactions to HS and had not received venom immunotherapy (VIT) did manifest a systemic reaction to a repeat HS. However, such reactions to a repeat HS were mild. There were no systemic reactions to a repeat HS in the limited number of children with previous cutaneous-only systemic reactions to HS who had been given a course of VIT. However, the authors concluded that VIT was not needed in children with just cutaneous reactions to HS.

The situation was quite different in children who previously had more severe, multi-organ systemic reactions to HS. Those who previously received a course of VIT had a much lower incidence of systemic reactions to a repeat HS than those who had not received VIT in the past. The authors concluded that VIT was indicated in this group, possibly for indefinite time duration in individuals with very severe systemic reactions to HS in the past.

Although, in this follow-up study from Johns Hopkins, systemic reactions to a repeat HS occurred in a small minority of those with histories of only large local reactions to a previous HS, such reactions were quite mild (3). Therefore, these authors and another very experienced group (4) feel that those with just large, local reactions are not at increased risk for severe systemic reactions to a repeat HS.

References

1. J. Allergy Clin Immunol. 2003 ;112:495-8
2. J Pediatr. 1983 ;102:361-5.
3. N Engl J Med.2004;351:668-74.
4. J Allergy Clin Immunol. 1984 ;74 (4 Pt 1):494-8.

 



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