Q:

11/27/2013
82 year old lady stung by yellow jacket (while on ACE inhibitor and beta blocker), she was stung twice. She went into cardiac arrest, intubated, defibrillated, epi drip but recovered. Medications (ACEI and beta blocker stopped). Six weeks later stung by one yellow jacket, had used epi right away at home, called 911, had anaphylaxis (respiratory, drop in BP), required multiple doses of epi. I saw her, has ImmunoCap positive to wasp 36.70 ku/L but negative to yellow jacket. I proceeded to skin test (I started at very low dose , 0.001ug/mL intradermal) to yellow jacket and she had 8mm. How should I proceed in desensitization? What dose to start with and what protocol do you suggest?

A:

Thank you for your inquiry.

I would initiate immunotherapy in your at a concentration of 1 or two logs lower than the concentration to which she reacted on intradermal testing. I would use the suggested protocol for dose escalation as is seen in the package insert of the product you are using. I do not know the brand that you are using, but a representative protocol for single venom immunotherapy can be found online here (Table 3).

Parenthetically, I would also obtain a baseline serum tryptase in your patient as a screening for potential mastocytosis.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology