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Stinging insect allergy and immunotherapy

Question:

8/10/2017
17 year-old male has allergic rhinitis and on AIT. Mother also c/o very large locals to insect stings. The locals extend past a joint. No systemic reactions. Mom reports that they have numerous carpenter bees in and around their home. They live on 3 1/2 acres property. She thought patient had local reactions to wasps but now thinks it could be carpenter bee. First reaction was on their front porch when he stepped on a carpenter bee (suspected insect type) and he developed a large local past his ankle and PCP gave prednisone and EpiPen prescription to carry.

Mom states at 10 years old, he was stung on his hand by an insect and developed a large local reaction that extended past the wrist and elbow and towards the shoulder. She recalls he was somewhat dizzy then also. It was treated with ice and Benadryl at home. She states he can get cellulitis when he has insect bites.

He was stung by yellow jacket at 7 years old on ear but normal reaction. No reaction to honeybees.

History previously of wasp but now mom is unsure. She Indications of large locals and high risk environmental for repeat reactions relayed to mother and patient does meet former criteria but avoids outdoors. However mom insistent of VIT since he is coming in for AIT. Patient 's intradermals positive to wasp, yellow jacket, yellow hornet, and white hornet at strongest 1 mcg/ml concentration.

I was unable to find information about carpenter bee cross reactivity with other venoms - are you aware? How would you advise proceeding with a mother insisting on venom shots for large locals to possible carpenter bee and not one of those tested? I was considering wasp shots, due to history of possible large locals to wasp also, but mother would like to mixed vespid also

Answer:

I performed a literature search and did not find much information about carpenter bee allergy so I contacted Dr. David B. K. Golden. Turns out there is little information about reactions to carpenter bees. There is minimal cross-reactivity with other venoms. There is a case report that states that carpenter bee venom contains mellitin. Mellitin is also present in the venom of apids, but it is not a major allergen. (I did not see a skin test result for honey bee in your case summary.) Carpenter bees are quite docile and will not attack, so the only way to get stung is to step on one or grab it with your hand. There is therefore very little risk of future carpenter bee stings if one is reasonably careful. Your patient is much more likely to have yellow jacket stings, or maybe wasp or hornet stings, than to get a carpenter bee sting.

Regarding large local reactions, the future risk of a systemic reaction of any severity is 7% and less than 3% for anaphylaxis. This is true in children and adults. There is evidence that venom immunotherapy can reduce the size and duration of future local reactions. Testing and venom immunotherapy for someone with a history of large local reactions could be considered, especially if there are special circumstances (frequent and unavoidable stings, frequent reactions, reduced quality of life or underlying medical conditions). Your patient meets criteria for positive skin test to the vespids. He has had primarily large local reactions, and therefore “does not require” VIT. Whether there was hypotension when he had slight dizziness cannot be known, but it is quite uncommon in children. The dizziness reported for the reaction at age 10 sounds suspicious for anaphylaxis. Since there may be a recall bias regarding the insects that caused the stings, I would recommend including all of those to which he tested positive in the treatment. Plus there is the risk of a future reaction to other venoms to which the patient has IgE. If mother feels strongly that VIT be administered, the suggestion is to include mixed vespid venom and maybe wasp venom. There are no commercially available extracts of carpenter bee venom for skin testing or treatment.

I am grateful for Dr Golden’s extremely informative input to this response.

I refer you to the 2016 Update Practice Parameter (Ann Allergy Asthma Immunol 118(2017):28-54 for further guidance.

Jacqueline A. Pongracic, MD, FAAAAI