Q:

6/25/2014  
6 year-old stung by a "bee" not exactly sure what kind in early August of 2013. She was stung on left hand and developed localized swelling and redness followed by redness of the face, hives all over her chest with swollen eyes. Denies any shortness of breath, tongue swelling however, there was a question about the throat itching. As per mother she was complaining of itching around the throat area but not clear if it was itching inside the throat or the skin over the throat.

Again she was stung by a bee and developed a mild local swelling on the forehead. As per mother this reaction developed quicker and became more generalized. Skin testing initially showed weakly positive reaction to wasp 4mm and white hornet 5mm (at one microgram concentration) which could be an irritant/false positive reaction. It was repeated twice and turned completely negative in March 2014.

RAST test showed very weakly positive reaction to white faced hornet (0.37) and yellow jacket (0.55) and it was repeated for yellow jacket and it gradually increased rom 0.55 to 0.75 and now up to 2.15.

Is she a candidate for Allergen Immunotherapy or any other testing?

A:

Thank you for your inquiry.

The decision to administer venom immunotherapy in your patient rests in large part upon how you interpret the nature of her reaction. In the simplest terms, if you interpret this event as an anaphylactic episode, then immunotherapy is indicated. If you do not, then according to the Guidelines, it is generally not indicated. But the guidelines do give great lee way, and the operative term is "generally".

These criteria are clearly set forth in our Parameters. For your convenience, I have copied below the section from the Parameters that deals with this issue. We know from adjudication of anaphylactic events that there are differences of opinion as to how physicians view such episodes. The most important decision of course rests upon your interpretation since you have had direct conversations with the mother and are in the best position to make this judgment. From what you have written, from my perspective, the event was not anaphylactic. However, as noted above, this is open to interpretation and argument. The key word, once again, in the Guidelines noted below is "generally". Physicians are certainly given the green light to interpret each event according to their own perspective but also, if they feel it clinically indicated, to overrule a strict interpretation of the Guidelines.

In summary, the information from the Guidelines copied below should be the basis for your decision, and you are in the best position to make the determination as to whether or not this was an anaphylactic event and whether or not, even if it was not an anaphylactic event, you would make an exception and treat this patient. The reasons for that could be the wishes of the family, your concern that an automatic epinephrine injector would not be used by the family, et cetera.

Therefore, in my opinion, your patient does not reach the strict criteria for the automatic initiation of venom immunotherapy (that is, an anaphylactic event in a 6 year-old), but I would in no way argue against initiation of immunotherapy if you disagreed with this interpretation or if you felt for any reason that you would be more comfortable treating this child.

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

"VIT is generally not necessary in children 16 years of age and younger who have experienced cutaneous systemic reactions without other systemic manifestations after an insect sting.

Cutaneous systemic reactions, such as urticaria, angioedema, or flushing and pruritus, can occur after an insect sting and can be severe. Prospective studies have shown that patients 16 years of age and younger who have experienced cutaneous systemic reactions without other allergic manifestations have approximately a 10% chance of having a systemic reaction if re-stung. If a systemic reaction does occur, it is likely to be limited to the skin, with less than a 5% risk of a more severe reaction and less than a 1% risk of life-threatening anaphylaxis.38,39 Therefore VIT is generally not necessary for patients 16 years of age and younger who have experienced only cutaneous systemic reactions; VIT is still an acceptable option in such patients if requested by the patient’s parents."

Source:
Stinging insect hypersensitivity: A practice parameter update 2011

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology