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Venom immunotherapy, reactions

Question:

2/16/2017
Adult male on venom immunotherapy for 2.5 years for bee/wasp/mixed vespid, reports that for the past four maintenance injections, he has experienced perioral and nasal numbness within 5 minutes of injection and "feels weird," denies respiratory symptoms. I plan to ask him to use antihistamine before injection and probably decrease the dose by 50%. He has not been stung since he started VIT but he does encounter bees at his workplace frequently. About 5 years ago he was stung, had shortness of breath, administered epinephrine and went to ER. Would you just reduce dose or lean towards stopping venom immunotherapy?

Answer:

Thank you for your question about symptoms after venom immunotherapy (VIT). It was not stated in the question but I will assume that the patient did not have any other objective or subjective symptoms of an IgE medicated reaction. It also was not revealed how long these symptoms lasted and what if any specific treatment was offered. I would be interested in how his shot sites looked after his VIT. In my experience, patients who have had IgE mediated reactions to AIT will have significant urticarial reactions at the shot site(s). While this is completely anecdotal it is helpful for me in evaluating potential shot reactions.

While one should assume that any reaction after AIT/VIT is from the immunotherapy, there is still a differential diagnosis to consider. The peri-oral “numbness” raises the possibility that this may have been paresthesias potential suggesting a hyperventilation type reaction. While not explicitly stated in the question, I assume that there were no new medicines or medical conditions that have been started or developed in the interim that could explain his symptoms. I am also assuming that he was not exercising prior to his VIT.

Since he has only been on VIT for 2.5 years, it is reasonable to expect that he would need several more years of VIT. Use of antihistamine prior to VIT is reasonable and I would suggest that this be done on a consistent basis and documented in the shot record. It is reasonable to consider decreasing his dose of VIT and based upon his clinical response make further dose adjustments with the goal of returning to optimal dose and frequency levels. If his symptoms were to persist despite dose adjustments, use of antihistamines and making sure no other pathology is relevant then one could consider rechecking his venom skin test and based upon these results make further clinical decisions.

I hope this has been helpful.

Andrew Murphy, MD, FAAAA