Q:

6/12/2014
I have a patient with a history of yellow jacket anaphylaxis in 03/07 and underwent multi-venom desensitization until 08/18/10. discontinued on his own. In 8/13 stung on upper lower lip and developed bilateral lip and cheek swelling despite ice and Benadryl. To ER - given epi x 2/Benadryl/Pepcid/Prednisone and ICU overnight stay for oral airway observation (no respiratory, laryngeal or tongue edema symptoms). Repeat skin test for venom - all negative.
SIgE Honey Bee 1.25/2
Wasp 1.66/2
WFH 1.76/2
Yellow Jacket 3.71/3
Yellow Hornet 0.67/1
Question what to do . . . I think I would desensitize to yellow jacket only.

A:

Thank you for your inquiry.

I am a little confused by the first sentence of the second paragraph of your inquiry - "stung by on upper lower lip," but I assume you mean there was a single sting on the upper portion of the lower lip by an unknown hymenoptera.

If this is the case, I would classify the reaction as a large local reaction which was threatening only by virtue of its location. I would not classify this reaction as a systemic reaction. According to our guidelines, your patient would not qualify for immunotherapy even though there was, on in vitro testing, evidence of sensitization. Sensitization, as you know, can occur in the absence of clinical reactivity or can be responsible for large local reactions without any systemic element. Therefore, the evidence of sensitivity alone does not indicate the need for venom immunotherapy.

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

Reference:
1. Golden DBK, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127(4):852-854.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology