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Venom testing with history of local reactions and likely honey bee exposure

Question:

2/16/2016  
I was sent two patients to rule out bee allergy. Both have been stung by "some bee-like" insects before without reactions beyond the local irritation and swelling. They do not know what insect stung them. They are planning to keep bees and were told they need to be tested. I am not sure if that is indicated considering the high rate of false positives on lab and skin testing. Does testing actually have a predictive value if there was no prior exposure? Is a lab test (IgE to hymenoptera) enough or do I have to do skin testing to clearly rule out the allergy? Should they have an epipen since there is a chance of anaphylaxis even in first exposure?

Answer:

With a history of local reactions (irritation and swelling) to an unknown insect, I would not recommend venom testing for honey bee, as I agree with you the predictive value of testing in this situation does not justify the procedure. False positive test results are an issue (Golden 1997; Bilo; Mosbech). There may be value in sting challenge testing (not performed in US) or new methods of testing, currently not readily available, which may have greater positive predictive value (Tankersley; Sturm; Golden 2014). I do not think an epinephrine autoinjector is necessary if there is not sufficient risk to justify allergy testing.

I shared your question and my comments with Dr. David B K Golden, an internationally recognized expert in insect allergy. Dr. Golden responded:
“I agree entirely with Dr. Ledford. First, let’s accept that these patients did not have any abnormal reaction to stings. The positive predictive value (I’m probably not being statistically correct in my terminology) of venom allergy tests in patients with known systemic reactions is in the range of 30-70% (ie, the frequency of repeat systemic reaction to future stings in these patients), about 50% on average. The PPV in patients with large local reactions is about 7%. In adults with no history of abnormal reaction (like your patients) the PPV was 17% in my retrospective study of field stings in sensitized normal adults (Golden 1997), but Sturm (2014) reported only 5/94 (5.3%) of such individuals had a systemic reaction to sting challenge.

I have heard of beekeepers being told they must or should be tested before beginning. As you know, the problem is the high frequency of asymptomatic sensitization (hence the above statistics). Those who have been stung in recent years have a 10-20% chance of having positive tests. And, of course, even if they are negative, they could become allergic at any time in the future. So I discourage testing in people with a negative history. The problem is everyone always wants the reassurance of a negative test, but they are not prepared to deal with a positive test. Would they have to go on VIT if it is positive, just to begin beekeeping? Or undergo several sting challenges (one is not enough)? The problem for the beekeepers associations or whoever is advising your patients on becoming beekeepers, is the liability of not checking for the allergy “just in case”.

Incidentally, you would indeed have to do both tests to really exclude (with 98% certainty) the allergy. And yes, it might be prudent for all beekeepers to be trained in the use of an epinephrine injector (and restaurant operators, and lifeguards, and school bus drivers).


1. Golden DBK, Marsh DG, Freidhoff LR, et al. Natural history of Hymenoptera venom sensitivity in adults. J Allergy Clin Immunol 1997;100:760-6.
2. Sturm GJ, Kranzelbinder B, Schuster C, et al. Sensitization to Hymenoptera venoms is common, but systemic sting reactions are rare. J Allergy Clin Immunol 2014;133:1635-43.”
3. Bilo, B. M., et al. "Diagnosis of Hymenoptera venom allergy." Allergy 60.11 (2005): 1339-1349.
4. Mosbech, H., et al. "Insect allergy. Predictive value of diagnostic tests: a three‐year follow‐up study." Clinical & Experimental Allergy 16.5 (1986): 433-440.
5. Golden, David B., et al. "Natural history of Hymenoptera venom sensitivity in adults." Journal of Allergy and Clinical Immunology 100.6 (1997): 760-766.
6. Sturm, G. J., et al. "The CD63 basophil activation test in Hymenoptera venom allergy: a prospective study." Allergy 59.10 (2004): 1110-1117.
7. Golden, David BK. "New directions in diagnostic evaluation of insect allergy." Current Opinion in Allergy and Clinical Immunology 14.4 (2014): 334-339.
8. Tankersley, Michael S., and Dennis K. Ledford. "Stinging insect allergy: state of the art 2015." The Journal of Allergy and Clinical Immunology: In Practice 3.3 (2015): 315-322.

I hope this information is of help to you and your patient.

All my best.
Dennis K. Ledford, MD, FAAAAI