I saw a 12 year-old girl who had been stung by a "yellow-jacket" (her words). About 45 minutes later, she began to "itch all over," describes having "welps" on her face. She also reported that her tongue felt "thick." I do not know where she was stung on her body. I assumed that she was NOT stung anywhere on her face. I took the approach that tongue feeling thick was a similar reaction to the welps and itching, and thus grouped all of these symptoms into the "cutaneous category." The practice parameters state that, for patients 16 and younger, who have experienced "only cutaneous systemic reactions," immunotherapy is NOT warranted. Therefore, I did NOT perform a full allergy evaluation. However, if one were to classify the reported sensation of tongue thickening into a category other than cutaneous, then immunotherapy would be warranted (assuming sensitization is shown), according to the parameters. In her case, I did perform skin testing, which was negative. Am I not following guidelines by not ordering specific IgE testing, and commencing with immunotherapy, if positive?


Thank you for your inquiry.

There has always been, and probably will always will be, a debate as to whether to interpret oral or posterior pharyngeal angioedema occurring with cutaneous symptoms as indicating the presence of anaphylaxis or an immediate hypersensitivity reaction limited to skin and subcutaneous tissue.

My opinion is in concert with yours. I would consider this child's reaction to be cutaneous/subcutaneous, and based upon the guidelines, would not initiate venom immunotherapy. I would therefore recommend your following the guidelines, and even if the skin tests were positive, I would have made the same decision.

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

Phil Lieberman, M.D.

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