Q:

4/23/2013
I am seeing 14 year old foster child with limited history. Four years ago suffered generalized urticarial and possible airway symptoms with fire ant sting and was treated at home. Then few weeks ago while playing volleyball felt sting on the thigh and immediately developed hives, swelling of the face and difficulty breathing, treated at urgent care with anti-histamines. Patient did not see the insect. Skin test strongly positive to all hymenoptera (fire ant, yellow jacket, hornets, wasp and honey bee). My question is about venom selection and number of immunotherapy injections. Am I ok to skip wasp and include mix vespids, honey bee and fire ant? Thank you.

A:

Thank you for your inquiry.

Perhaps the best way for me to answer your question is to simply take a quote from our most recent Practice Parameter regarding the management of venom immunotherapy. The quote is copied for you below:

“Selection of venoms for immunotherapy

Identification of the stinging insect responsible for a reaction can be aided by the geographic locality, the circumstances of the sting, and the appearance and location of the insect, nest, or both. Consensus data on which venoms to include for immunotherapy are not available. In the opinion of some authors, applying a knowledge of venom cross-reactivity and insect identification, the extract used for VIT need only contain a single venom, despite positive skin or in vitro test results for other stinging insects.106, 117 Other authors recommend that the extract contain venoms from all insects for which positive test results were obtained because of the potential for reaction to any venoms to which the patient is sensitized. 31, 37, 63, 118”

Source: Stinging insect hypersensitivity: A practice parameter update 2011, The Journal of Allergy and Clinical Immunology, Volume 127, Issue 4 , Pages 852-854.e23, April 2011. (numbered references in the quote above can be obtained from the article which is available online)

As you can see from this quote, there are differing opinions as to the selection of venoms for immunotherapy. Some authorities place strong relevance on cross-reactivities and others add any venom to which the patient has a positive skin test. I personally belong to the latter group.

Thus, in your case, I would personally include wasp venom.

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