Q:

I saw a 12 year-old female today who experienced generalized hives following a yellow-jacket sting two weeks ago. She also says that her tongue felt "thick." She did not have any other symptoms. If hives were her only symptom, I would not recommend immunotherapy, due to her young age. However, should the fact that her tongue felt thick change my management, and recommend IT? I want to err on the side of caution, of course.

A:

Thank you for your recent inquiry.

There is no definitive answer to your question. The decision as to whether or not to employ venom immunotherapy in this instance is purely based upon clinical judgment and personal interpretation of the significance of a "thick tongue."

My guess is that if you asked 10 different physicians as to how they might interpret this manifestation, you would probably get at least 5 different answers. In essence however the description of the event does not fit the clinical definition of anaphylaxis (1). Thus my own impression therefore, which is purely subjective, is that the sensation of a thick tongue has limited clinical importance in this case. And I would opt on the side of observation without immunotherapy. However, as noted above, this is not a "right or wrong" answer; simply a clinical opinion.

I wish I could be more definitive, but I do not think there is a definitively correct approach.

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

(1)Sampson H et al: Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Journal of Allergy and Clinical Immunology Vol. 117, Issue 2, Pages 391-397

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology