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Wilson JL, Wilson B. Venom Hypersensitivity. Med Clin North Am 2024; 108:757-776. [PMID: 38816116 DOI: 10.1016/j.mcna.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Stinging insects are a frequent cause of local and systemic hypersensitivity reactions, including anaphylaxis. For those with a history of life-threatening anaphylaxis, venom immunotherapy is effective, safe, and can be life-saving. Arachnids are a much less common source of envenomation through bites or stings and are less likely to cause a hypersensitivity reaction. However, recognizing the clinical manifestations when they do present is important for accurate diagnosis and treatment, and, when indicated, consideration of other diagnoses.
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Affiliation(s)
- J Lane Wilson
- Department of Community and Family Medicine, University of Missouri Kansas City School of Medicine, University Health Lakewood Medical Center, 7900 Lee's Summit Road, Kansas City, MO 64139, USA.
| | - Bridgid Wilson
- Department of Community and Family Medicine, University Health Lakewood Medical Center, Kansas City, MO, USA
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2
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Perčič S, Košnik M, Zaletel Kragelj L, Bojanić L, Kukec A. Risk Factors Associated with Severe Systemic Allergic Reaction after Wasp Sting in Subjects with a History of European Hornet Sting Allergy. Zdr Varst 2024; 63:66-72. [PMID: 38517021 PMCID: PMC10954242 DOI: 10.2478/sjph-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/05/2023] [Indexed: 03/23/2024] Open
Abstract
Aim To make the treatment approach in patients suffering a European hornet sting allergy reaction more personalized, preparing them also for possible future risks. Methods In Slovenia an extended retrospective observational cohort epidemiological study about the natural history of Hymenoptera venom sensitivity is in progress. The study is based on data from the healthcare records of the University Clinic Golnik (UCG) and data collected by a questionnaire sent to patients from May 2019 to April 2021. For a pilot study, we selected patients who were referred to UCG because of an allergic reaction to European hornet sting and had been re-stung later by a wasp (n=68). The association between severe systemic allergic reactions (SSAR) after wasp sting and potential risk factors in subjects with a history of hornet sting allergy was assessed univariately using the likelihood ratio test. Results Among 68 European hornet allergic patients 27 reacted with an SSAR and 41 reacted with a mild SAR. Among 27 patients with SSAR, 4 reacted with an SSAR also to a subsequent wasp sting. Among 41 patients with a mild European hornet sting SAR nobody reacted with an SSAR to a subsequent wasp sting. The association between the severity of the wasp SAR reaction in European hornet allergic patients was statistically significant (p=0.022). Conclusion Our results suggest that patients with severe European hornet SAR should be considered for wasp venom immunotherapy or prophylactic prescription of epinephrine auto-injector as they are at risk for an SSAR also after wasp string.
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Affiliation(s)
- Simona Perčič
- University of Ljubljana, Faculty of Medicine, Vrazov trg 2, 1000Ljubljana, Slovenia
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204Golnik, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Internal Medicine, Zaloška cesta 7, 1000Ljubljana, Slovenia
| | - Lijana Zaletel Kragelj
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000Ljubljana, Slovenia
| | - Lidija Bojanić
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik 36, 4204Golnik, Slovenia
| | - Andreja Kukec
- National Institute of Public Health, Trubarjeva cesta 2, 1000Ljubljana, Slovenia
- University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000Ljubljana, Slovenia
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Korošec P, Sturm GJ, Lyons JJ, Marolt TP, Svetina M, Košnik M, Zidarn M, Kačar M, Frelih N, Lalek N, Luzar AD, Zver S, Škerget M, Czarnobilska E, Dyga W, Grle SP, Samarzija M, Arzt-Gradwohl L, Čerpes U, Porebski G, Pevec B, Schadelbauer E, Kopač P, Šelb J, Rijavec M. High burden of clonal mast cell disorders and hereditary α-tryptasemia in patients who need Hymenoptera venom immunotherapy. Allergy 2024. [PMID: 38477502 DOI: 10.1111/all.16084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/07/2024] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND In patients who require venom immunotherapy (VIT), there is a need to identify underlying mast cell (MC) disorders since these may affect the risk and severity of future sting reactions and the long-term effectiveness of VIT. METHODS 1319 individuals with Hymenoptera venom allergy (HVA) who needed VIT from referral centers in Slovenia, Austria, Croatia, and Poland underwent examination for KIT p.D816V in peripheral blood leukocytes (PBL) using a highly sensitive PCR test and tryptase genotyping by digital droplet PCR. We also included 183 control individuals with large local reactions (LLRs) to Hymenoptera stings and with asymptomatic sensitization to Hymenoptera venoms. RESULTS 285 of 1319 individuals recommended for VIT (21.6%) were positive for KIT p.D816V in PBL, preferably those who present with severe reaction (33.9% [n = 207 of 610] with Ring-Messmer grade 3-4 vs. 11% [n = 78 of 709] with Grade 1-2; p < .0001), whereas only 1.3% (n = 2 of 152) of controls with LLR and none with asymptomatic sensitization (n = 31) had KIT p.D816V. KIT p.D816V allelic burden was higher in those with severe reaction (median 0.018% [n = 207] in Grade 3-4 vs. 0.001% [n = 78] in Grade 1-2; p < .0001), and the majority had normal baseline serum tryptase levels (69% [n = 196 of 285]). All KIT p.D816V-positive individuals (n = 41) who underwent bone marrow (BM) biopsy were found to have underlying clonal diseases, principally BM mastocytosis. HαT was also associated with severe HVA and symptoms (p < .01), and remarkably, 31.0% (n = 31 of 100) were found to have concomitant KIT p.D816V. Concomitant HαT and KIT p.D816V showed an additive effect, and having both was associated with the highest risk for severe HVA, even higher than having either HαT or KIT p.D816V alone (OR = 3.8; p < .01). CONCLUSIONS By employing prospective universal tryptase genotyping and examination for KIT p.D816V in PBL in large HVA populations, we have demonstrated a high burden of clonal MC disorders and HαT in patients who require VIT.
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Affiliation(s)
- Peter Korošec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Gunter J Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Manca Svetina
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mitja Košnik
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mihaela Zidarn
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Mark Kačar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nina Frelih
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Nika Lalek
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Ajda Demšar Luzar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Samo Zver
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Matevž Škerget
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
- The Department of Hematology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Dyga
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Sanja Popović Grle
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Miroslav Samarzija
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Urban Čerpes
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Branko Pevec
- Clinic for Respiratory Diseases Jordanovac, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Eva Schadelbauer
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Peter Kopač
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
- Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Chan HH, Burrows AK, Hosgood G, Ghubash R. Sensitivity of a Hymenoptera serological immunoglobulin (Ig)E assay for the diagnosis of venom hypersensitivity in dogs. Vet Dermatol 2023; 34:543-553. [PMID: 37485613 DOI: 10.1111/vde.13194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/15/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Hymenoptera envenomation with honey bee (Apis mellifera) and paper wasp (Polistes spp.) may cause life-threatening anaphylaxis in dogs. In human patients, clinical history, intradermal testing (IDT) and measurement of allergen-specific serological immunoglobulin (Ig)E (sIgE) are used to support a diagnosis of Hymenoptera venom hypersensitivity. The utility of venom allergen-specific sIgE has not yet been evaluated for this purpose in dogs. OBJECTIVES The objective of the study was to investigate the sensitivity (sn), specificity (sp) and positive predictive value (PPV) of honey bee and paper wasp serological titres using a commercially available sIgE assay [VARL (Veterinary Allergen Reference Laboratory) Liquid Gold] against clinical history for a diagnosis of Hymenoptera hypersensitivity in dogs. MATERIALS AND METHODS Honeybee and paper wasp IgE serum titres were measured in 15 client-owned dogs with a diagnosis of Hymenoptera venom hypersensitivity based on a history of anaphylaxis, owner observation of Hymenoptera, and positive IDT to bee and/or wasp; and in 10 client-owned dogs with no known history of anaphylaxis or Hymenoptera exposure and a negative IDT to bee and wasp. RESULTS Analysis of receiver operating characteristic (ROC) curves demonstrate that a VARL score cut-off of one of six for honeybee yields Sn, Sp and PPV of 40%, 60% and 60%, respectively, and two of six for wasp yields Sn, Sp and PPV of 25%, 78% and 60%, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Owing to the poor sensitivity and PPV of sIgE assays for both bee and wasp hypersensitivity in dogs with known envenomation and anaphylaxis, the use of sIgE cannot be recommended as a tool for venom identification.
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Affiliation(s)
- Hilary H Chan
- Animal Dermatology Clinic Perth, The Animal Hospital Murdoch University, Murdoch, Western Australia, Australia
| | - Amanda K Burrows
- Animal Dermatology Clinic Perth, The Animal Hospital Murdoch University, Murdoch, Western Australia, Australia
| | - Giselle Hosgood
- College of Veterinary Medicine, The Animal Hospital Murdoch University, Murdoch, Western Australia, Australia
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Ieven T, Coorevits L, Vandebotermet M, Tuyls S, Vanneste H, Santy L, Wets D, Proost P, Frans G, Devolder D, Breynaert C, Bullens DMA, Schrijvers R. Endotyping of IgE-Mediated Polyethylene Glycol and/or Polysorbate 80 Allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3146-3160. [PMID: 37380070 PMCID: PMC10291891 DOI: 10.1016/j.jaip.2023.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 06/07/2023] [Accepted: 06/13/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Polyethylene glycol (PEG) and polysorbate 80 (PS80) allergy preclude from SARS-CoV-2 vaccination. The mechanism(s) governing cross-reactivity and PEG molecular weight dependence remain unclear. OBJECTIVES To evaluate PEGylated lipid nanoparticle (LNP) vaccine (BNT162b2) tolerance and explore the mechanism of reactivity in PEG and/or PS80 allergic patients. METHODS PEG/PS80 dual- (n = 3), PEG mono- (n = 7), and PS80 mono-allergic patients (n = 2) were included. Tolerability of graded vaccine challenges was assessed. Basophil activation testing on whole blood (wb-BAT) or passively sensitized donor basophils (allo-BAT) was performed using PEG, PS80, BNT162b2, and PEGylated lipids (ALC-0159). Serum PEG-specific IgE was measured in patients (n = 10) and controls (n = 15). RESULTS Graded BNT162b2 challenge in dual- and PEG mono-allergic patients (n = 3/group) was well tolerated and induced anti-spike IgG seroconversion. PS80 mono-allergic patients (n = 2/2) tolerated single-dose BNT162b2 vaccination. Wb-BAT reactivity to PEG-containing antigens was observed in dual- (n = 3/3) and PEG mono- (n = 2/3), but absent in PS80 mono-allergic patients (n = 0/2). BNT162b2 elicited the highest in vitro reactivity. BNT162b2 reactivity was IgE mediated, complement independent, and inhibited in allo-BAT by preincubation with short PEG motifs, or detergent-induced LNP degradation. PEG-specific IgE was only detectable in dual-allergic (n = 3/3) and PEG mono-allergic (n = 1/6) serum. CONCLUSION PEG and PS80 cross-reactivity is determined by IgE recognizing short PEG motifs, whereas PS80 mono-allergy is PEG-independent. PS80 skin test positivity in PEG allergics was associated with a severe and persistent phenotype, higher serum PEG-specific IgE levels, and enhanced BAT reactivity. Spherical PEG exposure via LNP enhances BAT sensitivity through increased avidity. All PEG and/or PS80 excipient allergic patients can safely receive SARS-CoV-2 vaccines.
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Affiliation(s)
- Toon Ieven
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Lieve Coorevits
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Martijn Vandebotermet
- Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium; Department of Pulmonology, AZ Groeninge Hospital, Kortrijk, Belgium
| | - Sebastiaan Tuyls
- Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium; Department of Pulmonology, GZA St-Augustinus Hospital, Wilrijk, Belgium
| | - Hélène Vanneste
- Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium; Department of Pulmonology, AZ Vesalius, Tongeren, Belgium
| | - Lisa Santy
- Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium; Department of Internal Medicine, Division of Pulmonology, St-Jozefskliniek, Izegem, Belgium
| | - Dries Wets
- Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Paul Proost
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Glynis Frans
- Clinical Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - David Devolder
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Christine Breynaert
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium
| | - Dominique M A Bullens
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Rik Schrijvers
- KU Leuven Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium; Department of General Internal Medicine, Division of Allergy and Clinical Immunology, University Hospitals Leuven, Leuven, Belgium.
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Rostaher A, Fischer NM, Vigani A, Steblaj B, Martini F, Brem S, Favrot C, Kosnik M. Hymenoptera Venom Immunotherapy in Dogs: Safety and Clinical Efficacy. Animals (Basel) 2023; 13:3002. [PMID: 37835609 PMCID: PMC10571593 DOI: 10.3390/ani13193002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/17/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Hymenoptera allergens are the main triggers for anaphylaxis in susceptible dogs and humans. Hymenoptera venom specific immunotherapy (VIT), the only disease-modifying treatment, has the potential to prevent future life-threatening reactions in human patients. Prospective clinical data on VIT efficacy in dogs are currently lacking. Therefore, the aim of this study was to show that VIT is not only safe but also efficacious in preventing anaphylaxis in dogs allergic to Hymenoptera. This uncontrolled prospective clinical trial included 10 client-owned dogs with a history of anaphylaxis following repeated Hymenoptera stings. The sensitization to bee and wasp allergens was demonstrated by intradermal testing (IDT) and allergen-specific IgE serology. For VIT induction (induction phase), dogs received a shortened rush immunotherapy protocol with aqueous allergens, which was then followed by monthly injections of 100 µg of alum-precipitated allergen (maintenance phase). VIT efficacy was determined by observing patients' clinical reactions to re-stings. No systemic adverse events were seen during the induction and maintenance phases. From the seven re-stung dogs, only one developed a mild angioedema at the site of the sting; the remaining dogs were asymptomatic. These results show that VIT represents a safe and effective treatment option for Hymenoptera-allergic dogs.
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Affiliation(s)
- Ana Rostaher
- Dermatology Unit, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (N.M.F.); (F.M.); (S.B.); (C.F.)
| | - Nina Maria Fischer
- Dermatology Unit, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (N.M.F.); (F.M.); (S.B.); (C.F.)
| | - Alessio Vigani
- Division of Small Animal Emergency and Critical Care, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
| | - Barbara Steblaj
- Section of Anaesthesiology, Department of Clinical Diagnostics and Services, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland;
| | - Franco Martini
- Dermatology Unit, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (N.M.F.); (F.M.); (S.B.); (C.F.)
| | - Salina Brem
- Dermatology Unit, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (N.M.F.); (F.M.); (S.B.); (C.F.)
| | - Claude Favrot
- Dermatology Unit, Clinic for Small Animal Internal Medicine, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland; (N.M.F.); (F.M.); (S.B.); (C.F.)
| | - Mitja Kosnik
- Division of Allergy, University Clinic of Respiratory and Allergic Diseases Golnik, 4204 Golnik, Slovenia;
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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Czolk R, Ruiz‐Castell M, Hunewald O, Wanniang N, Le Coroller G, Hilger C, Vaillant M, Fagherazzi G, Morel‐Codreanu F, Ollert M, Kuehn A. Novel, computational IgE-clustering in a population-based cross-sectional study: Mapping the allergy burden. Clin Transl Allergy 2023; 13:e12292. [PMID: 37746799 PMCID: PMC10478827 DOI: 10.1002/clt2.12292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Even though the prevalence of allergies is increasing, population-based data are still scarce. As a read-out for chronic inflammatory information, new methods are needed to integrate individual biological measurements and lifestyle parameters to mitigate the consequences and costs of allergic burden for society. METHODS More than 480.000 data points were collected from 1462 Luxembourg adults during the representative, cross-sectional European Health Examination Survey, spanning health and lifestyle reports. Deep IgE-profiles based on unsupervised clustering were correlated with data of the health survey. FINDINGS 42.6% of the participants reported a physician-diagnosed allergy and 44% were found to be IgE-positive to at least one allergen or extract. The main sensitization sources were tree pollens followed by grass pollens and mites (52.4%, 51.8% and 40.3% of sensitized participants respectively), suggesting seasonal as well as perennial burden. The youngest group of participants (25-34 years old) showed the highest burden of sensitization, with 18.2% of them having IgE to 10 or more allergen groups. Unsupervised clustering revealed that the biggest cluster of 24.4% of participants was also the one with the highest medical need, marked by their multi-sensitization to respiratory sources. INTERPRETATION Our novel approach to analyzing large biosample datasets together with health information allows the measurement of the chronic inflammatory disease burden in the general population and led to the identification of the most vulnerable groups in need of better medical care.
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Affiliation(s)
- Rebecca Czolk
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
- Faculty of Science, Technology and MedicineUniversity of LuxembourgEsch‐sur‐AlzetteLuxembourg
| | - Maria Ruiz‐Castell
- Epidemiology and Public Health Research UnitDepartment of Precision HealthLuxembourg Institute of HealthStrassenLuxembourg
| | - Oliver Hunewald
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
| | - Naphisabet Wanniang
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
- Faculty of Science, Technology and MedicineUniversity of LuxembourgEsch‐sur‐AlzetteLuxembourg
| | - Gwenaëlle Le Coroller
- Competence Center for Methodology and StatisticsTranslational Medicine Operations HubLuxembourg Institute of HealthStrassenLuxembourg
| | - Christiane Hilger
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
| | - Michel Vaillant
- Competence Center for Methodology and StatisticsTranslational Medicine Operations HubLuxembourg Institute of HealthStrassenLuxembourg
| | - Guy Fagherazzi
- Epidemiology and Public Health Research UnitDepartment of Precision HealthLuxembourg Institute of HealthStrassenLuxembourg
| | - Françoise Morel‐Codreanu
- Department of Allergology and ImmunologyCentre Hospitalier de Luxembourg‐Kanner KlinikLuxembourgLuxembourg
| | - Markus Ollert
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
- Department of Dermatology and Allergy CenterOdense Research Center for AnaphylaxisOdense University HospitalUniversity of Southern DenmarkOdenseDenmark
| | - Annette Kuehn
- Department of Infection and ImmunityLuxembourg Institute of HealthEsch‐sur‐AlzetteLuxembourg
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Bonadonna P, Korosec P, Nalin F, Golden DBK. Venom Anaphylaxis: Decision Points for a More Aggressive Workup. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2024-2031. [PMID: 37119981 DOI: 10.1016/j.jaip.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/01/2023]
Abstract
Diagnostic testing of patients who present for evaluation of insect venom allergy can involve many levels of investigation. A detailed initial history is critical for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict severe future sting reactions and underlying mast cell disorders. Venom skin tests and specific IgE measurement can confirm the diagnosis but have limited positive predictive value for the frequency and severity of future sting reactions. Testing for serum IgE to recombinant venom component allergens can distinguish true allergy from cross-reactivity to honey bee and yellowjacket venoms. Basophil activation tests can improve the detection of venom allergy and predict the severity of reactions and the efficacy of venom immunotherapy but are limited in availability. An elevated basal serum tryptase level is an important marker for severe sting anaphylaxis and underlying mast cell disorders (eg, hereditary α-tryptasemia and clonal mast cell disease). When there is high suspicion (eg, using the Red Espanola de Mastocytosis score), bone marrow biopsy is the definitive tool to characterize mast cell disorders that are associated with the most severe outcomes in patients with insect sting allergy.
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Affiliation(s)
| | - Peter Korosec
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia; Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia; Medical Faculty, University of Maribor, Maribor, Slovenia
| | | | - David B K Golden
- Dvision of Allergy and Clinical Immunology, Johns Hopkins School of Medicine, Johns Hopkins University, Baltimore, Md.
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Wilson JL, Wilson B. Venom Hypersensitivity. Prim Care 2023; 50:305-324. [PMID: 37105609 DOI: 10.1016/j.pop.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
Stinging insects are a frequent cause of local and systemic hypersensitivity reactions, including anaphylaxis. For those with a history of life-threatening anaphylaxis, venom immunotherapy is effective, safe, and can be life-saving. Arachnids are a much less common source of envenomation through bites or stings and are less likely to cause a hypersensitivity reaction. However, recognizing the clinical manifestations when they do present is important for accurate diagnosis and treatment, and, when indicated, consideration of other diagnoses.
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10
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Wings and stings: Hymenoptera on vacation. Ann Allergy Asthma Immunol 2023; 130:429-437. [PMID: 36702244 DOI: 10.1016/j.anai.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/11/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023]
Abstract
Traveling to different regions, one might encounter a species to which they have a known allergy, or other related and unrelated species. A first-time systemic reaction can occur while on vacation, even in those with previous asymptomatic stings. Three main groups of Hymenoptera are responsible for most sting reactions. Honey bee species are virtually identical around the world. Among social wasps (family Vespidae), the yellowjacket (genus Vespula and Dolichovespula) and hornet (genus Vespa) venoms have almost complete cross-reactivity, whereas paper wasp (genus Polistes) venoms show only partial cross-reactivity with other vespid venoms. Venom immunotherapy (VIT) confers 80% to 95% protection against related insects, though isolated species of paper wasps and yellowjackets exist in every country that may be distinct from the ones at home. Those allergic to imported fire ants (genus Solenopsis) in the United States should not react to other ant species around the world. Stinging ants belong to several unrelated subfamilies in different geographic regions, which do not have cross-reactive venom. The chances of encountering specific species of Hymenoptera at a traveler's destination vary by location, planned activities, and season. In this article, we discuss special considerations for traveling, including distribution of stinging insects around the world, risk factors for more severe reactions, ways to prepare for a trip, and when allergist examination or treatment may be helpful before travel.
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11
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Kačar M, Rijavec M, Šelb J, Korošec P. Clonal mast cell disorders and hereditary α-tryptasemia as risk factors for anaphylaxis. Clin Exp Allergy 2023; 53:392-404. [PMID: 36654513 DOI: 10.1111/cea.14264] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/12/2022] [Accepted: 11/23/2022] [Indexed: 01/20/2023]
Abstract
The association between Hymenoptera venom-triggered anaphylaxis (HVA) and clonal mast cell-related disorders (cMCD) has been known for decades. However, recent breakthroughs in peripheral blood screening for KIT p.D816V missense variant have revealed the true extent of this clinical association whilst adding to our understanding of the underlying aetiology. Thus, recent large studies highlighted the presence of KIT p.D816V among 18.2% and 23% of patients with severe Hymenoptera venom-triggered anaphylaxis. A significant proportion of those patients have normal serum basal tryptase (BST) levels, with no cutaneous findings such as urticaria pigmentosa or other systemic findings such as organomegaly that would have suggested the presence of cMCD. These findings of an increased prevalence suggest that the impact of cMCD on anaphylaxis could be clinically underestimated and that the leading question for clinicians could be changed from 'how many patients with cMCD have anaphylaxis?' to 'how many patients with anaphylaxis have cMCD?'. The discovery of hereditary α-tryptasemia (HαT)-a genetic trait caused by an increased copy number of the Tryptase Alpha/Beta 1 (TPSAB1) gene-, first described in 2016, is now known to underlie the majority of cases of elevated BST outside of cMCD and chronic kidney disease. HαT is the first common heritable genetic modifier of anaphylaxis described, and it is associated with increased risk for severe HVA (relative risk = 2.0), idiopathic anaphylaxis, and an increased prevalence of anaphylaxis in patients with cMCD, possibly due to the unique activity profile of α/β -tryptase heterotetramers that may potentiate immediate hypersensitivity reaction severity. Our narrative review aims to highlight recent research to have increased our understanding of cMCD and HαT, through recent lessons learned from studying their association with HVA. Additionally, we examined the studies of mast cell-related disorders in food and drug allergy in an effort to determine whether one should also consider cMCD and/or HαT in cases of severe anaphylaxis triggered by food or drugs.
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Affiliation(s)
- Mark Kačar
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Matija Rijavec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Biotechnical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Julij Šelb
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Peter Korošec
- University Hospital of Respiratory and Allergic Diseases, Golnik, Slovenia.,Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
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12
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Carlson JC, Hajirawala M, Hein N. Diagnosis and Management of Insect Allergy: Barriers and Facilitators in the United States. J Asthma Allergy 2022; 15:1773-1781. [PMID: 36544562 PMCID: PMC9762263 DOI: 10.2147/jaa.s364867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
While guidelines recommend testing and treatment for patients with venom-induced anaphylaxis to prevent morbidity and mortality, significant barriers prevent most patients from receiving the evaluation and treatments that they need. This review examines these barriers in the United States along with the facilitators that can be used to overcome them.
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Affiliation(s)
- John C Carlson
- Department of Pediatrics, Ochsner Health System, New Orleans, LA, USA,Correspondence: John C Carlson, Department of Pediatrics, Ochsner Health System, 1315 Jefferson Hwy, New Orleans, LA, 20121, USA, Tel +1-504-842-3900, Fax +1-504-842-5848, Email
| | - Monica Hajirawala
- Department of Pediatric Allergy and Immunology, University of South Florida, St. Petersburg, FL, USA
| | - Nina Hein
- Department of Allergy and Clinical Immunology, Tulane University, New Orleans, LA, USA
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13
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Matysiak J, Matuszewska E, Packi K, Klupczyńska-Gabryszak A. Diagnosis of Hymenoptera Venom Allergy: State of the Art, Challenges, and Perspectives. Biomedicines 2022; 10:2170. [PMID: 36140269 PMCID: PMC9496208 DOI: 10.3390/biomedicines10092170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 11/24/2022] Open
Abstract
Hymenoptera venom allergy is the most common cause of anaphylaxis in adults and the second-most frequent in children. The proper diagnosis of this life-threatening allergy remains a challenge. This review focuses on the current knowledge regarding diagnostics of Hymenoptera venom allergy. The paper includes a brief description of the representatives of Hymenoptera order and the composition of their venoms. Then, diagnostic tests for allergy to Hymenoptera venom are described. Common diagnostic problems, especially double positivity in tests for IgE antibodies specific to honeybee and wasp venom, are also discussed. Special attention is paid to the search for new diagnostic capabilities using modern methodologies. Multidimensional molecular analysis offers an opportunity to characterize changes in body fluids associated with Hymenoptera venom allergy and yields a unique insight into the cell status. Despite recent developments in the diagnostics of Hymenoptera venom allergy, new testing methodologies are still needed to answer questions and doubts we have.
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Affiliation(s)
- Joanna Matysiak
- Faculty of Health Sciences, Calisia University-Kalisz, 62-800 Kalisz, Poland
| | - Eliza Matuszewska
- Department of Inorganic and Analytical Chemistry, Poznan University of Medical Sciences, 60-806 Poznan, Poland; (E.M.); (K.P.); (A.K.-G.)
| | - Kacper Packi
- Department of Inorganic and Analytical Chemistry, Poznan University of Medical Sciences, 60-806 Poznan, Poland; (E.M.); (K.P.); (A.K.-G.)
- AllerGen, Center of Personalized Medicine, 97-300 Piotrkow Trybunalski, Poland
| | - Agnieszka Klupczyńska-Gabryszak
- Department of Inorganic and Analytical Chemistry, Poznan University of Medical Sciences, 60-806 Poznan, Poland; (E.M.); (K.P.); (A.K.-G.)
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14
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Hollstein MM, Matzke SS, Lorbeer L, Forkel S, Fuchs T, Lex C, Buhl T. Intracutaneous Skin Tests and Serum IgE Levels Cannot Predict the Grade of Anaphylaxis in Patients with Insect Venom Allergies. J Asthma Allergy 2022; 15:907-918. [PMID: 35836970 PMCID: PMC9274911 DOI: 10.2147/jaa.s367272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/23/2022] [Indexed: 11/29/2022] Open
Abstract
Background Allergies against Hymenoptera venoms are a major cause of severe anaphylaxis. Risk assessment for subjects with suspected allergy is difficult because there are currently no biomarkers that predict the likelihood of high-grade anaphylaxis other than several associated comorbidities. Objective We investigated the relationship between the severity of anaphylaxis and the results of intracutaneous skin tests (ICTs) together with serum levels of tryptase, total IgE, and venom-specific IgE, IgG, and IgG4. Methods We performed a retrospective evaluation of 194 patients who presented to a single medical center with allergies to bee venoms (Apis mellifera, Bombus spp.; n=24, 12.4%), vespid venoms (Vespula spp., Vespa spp., Polistes spp.; n=169, 87.1%), or both (n=1, 0.5%). Results Index bee stings occurred earlier in the year than vespid stings, although the latter were reported more frequently overall. On average, subjects who previously experienced grade IV anaphylaxis required higher dosages of venom to yield positive ICTs than those who exhibited lower grade responses. Patients diagnosed with grade IV anaphylaxis exhibited significantly lower levels of venom-specific IgE and IgG and trended toward elevated levels of tryptase. No significant differences in average levels of venom-specific IgG4 and total IgE were observed. Conclusion Our findings reveal that intracutaneous skin testing and levels of venom-specific IgE do not predict the degree of anaphylaxis that develops in patients with venom allergy. Furthermore, the month of the index sting is not a reliable means to differentiate bee from vespid stings in patients presenting with an uncertain history.
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Affiliation(s)
- Moritz M Hollstein
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Silke S Matzke
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Lisa Lorbeer
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Susann Forkel
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
| | - Christiane Lex
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology with Pediatric Pneumology, University Medical Centre Göttingen, Göttingen, Germany
| | - Timo Buhl
- Department of Dermatology, Venereology and Allergology, University Medical Centre Göttingen, Göttingen, Germany
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15
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Perčič S, Bojanić L, Košnik M, Kukec A. Natural History of the Hymenoptera Venom Sensitivity Reactions in Adults: Study Design. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074319. [PMID: 35409999 PMCID: PMC8998790 DOI: 10.3390/ijerph19074319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 12/10/2022]
Abstract
Background: Allergic reactions to Hymenoptera stings can have varying levels of severity, according to the Müller grading system. Methods: By an epidemiological concept, this is a retrospective cohort study. The observed cohort was represented by patients referred to the University Clinic Golnik due to Hymenoptera allergic reaction in the period from 1997 to 2015. From the immunological database of the University Clinic Golnik, we obtained laboratory data (sIgE, skin tests and basophil activation test). The clinical characteristics of patients were obtained from BIRPIS. With the help of a questionnaire, which was sent to each patient in the period from May 2019 to April 2021, we obtained epidemiological data. For the assessment of the association between the severity of allergic reaction for the observed outcome, the severity of the first allergic reaction after Hymenoptera sting was used. Other variables were grouped according to risk factors. Discussion: We will identify the risk factors that could play an important role in a severe systemic reaction: the aetiology of the Hymenoptera sting, sex, age, history and severity of previous systemic reactions, being re-stung in an interval of two months, the frequency of re-stings, atopy, genetic predisposition, preventive medication use, other medication use, beekeeping or living next to beehives and why immunotherapy was not taken. Laboratory data will also be analysed to determine if there is any association with laboratory tests and the severity of the allergic reactions after Hymenoptera stings. Conclusions: Several new approaches are introduced in the study design. The most important is that the protocol covers epidemiological data gained from the questionnaire, as well as clinical data gained from the Immunological database and BIRPIS database. We expect to obtain significant results that will explain the risk factors for the natural history of Hymenoptera sting allergic reactions and will help allergologists, as well as general doctors, when facing those patients allergic to Hymenoptera venom without immunotherapy.
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Affiliation(s)
- Simona Perčič
- National Institute of Public Health, Centre for Environmental Health, Zaloška 29, 1000 Ljubljana, Slovenia;
- Correspondence:
| | - Lidija Bojanić
- The University Clinic of Pulmonary and Allergic Diseases Golnik, Golnik 36, 4204 Golnik, Slovenia; (L.B.); (M.K.)
| | - Mitja Košnik
- The University Clinic of Pulmonary and Allergic Diseases Golnik, Golnik 36, 4204 Golnik, Slovenia; (L.B.); (M.K.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, Zaloška 7, 1000 Ljubljana, Slovenia
| | - Andreja Kukec
- National Institute of Public Health, Centre for Environmental Health, Zaloška 29, 1000 Ljubljana, Slovenia;
- Department of Public Health, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia
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16
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Tracy JM. Testing for Venom Allergy: Should We Change Testing Order? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:844-845. [PMID: 35272787 DOI: 10.1016/j.jaip.2021.12.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Affiliation(s)
- James M Tracy
- Department of Pediatrics, University of Nebraska College of Medicine, Omaha, Neb; Allergy, Asthma, and Immunology Associates, PC, Omaha, Neb.
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17
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Lindström I, Hölttä P, Suuronen K, Suomela S, Suojalehto H. High prevalence of sensitization to bumblebee venom among greenhouse workers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:637-639. [PMID: 34563737 DOI: 10.1016/j.jaip.2021.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Irmeli Lindström
- Finnish Institute of Occupational Health, Occupational Medicine Department, Helsinki, Finland.
| | - Pirjo Hölttä
- Finnish Institute of Occupational Health, Occupational Medicine Department, Helsinki, Finland
| | - Katri Suuronen
- Finnish Institute of Occupational Health, Occupational Medicine Department, Helsinki, Finland
| | - Sari Suomela
- Finnish Institute of Occupational Health, Occupational Medicine Department, Helsinki, Finland
| | - Hille Suojalehto
- Finnish Institute of Occupational Health, Occupational Medicine Department, Helsinki, Finland
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18
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Abstract
Introduction: Idiopathic anaphylaxis (IA) is a diagnosis of exclusion and is based on the inability to identify a causal relationship between a trigger and an anaphylactic event, despite a detailed patient history and careful diagnostic assessment. The prevalence of IA among the subset of people who experienced anaphylaxis is challenging to estimate and varies widely, from 10 to 60%; most commonly noted is ∼20% in the adult anaphylactic population. Comorbid atopic conditions, such as food allergy, allergic rhinitis, and asthma, are present in up to 48% of patients with IA. Improved diagnostic technologies and an increased understanding of conditions that manifest with symptoms associated with anaphylaxis have improved the ability to determine a more accurate diagnosis for patients who may have been initially diagnosed with IA. Methods: Literature search was conducted on PubMed, Google Scholar and Embase. Results: Galactose-α-1,3-galactose (α-gal) allergy, mast cell disorders, and hereditary a-tryptasemia are a few differential diagnoses that should be considered in patients with IA. Unlike food allergy, when anaphylaxis occurs within minutes to 2 hours after allergen consumption, α-gal allergy is a 3-6-hour delayed immunoglobulin E-mediated anaphylactic reaction to a carbohydrate epitope found in red meat (e.g., beef, lamb, pork). The more recently described hereditary α-tryptasemia is an inherited autosomal dominant genetic trait caused by increased germline copies of tryptase human gene alpha-beta 1 (TPSAB1), which encodes α tryptase and is associated with elevated baseline serum tryptase. Acute management of IA consists of carrying an epinephrine autoinjector to be administered immediately at the first signs of anaphylaxis. Long-term management for IA with antihistamines and other agents aims to potentially reduce the frequency and severity of the anaphylactic reactions, although the evidence is limited. Biologics are potentially steroid-sparing for patients with IA; however, more research on IA therapies is needed. Conclusion: The lack of diagnostic criteria, finite treatment options, and intricacies of making a differential diagnosis make IA challenging for patients and clinicians to manage.
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Affiliation(s)
- Alyssa G. Burrows
- From the Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Ontario, Canada
| | - Anne K. Ellis
- From the Allergy Research Unit, Kingston Health Sciences Center - KGH Site, Kingston, Ontario, Canada
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19
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Cerpes U, Repelnig ML, Legat FJ. Itch in Hymenoptera Sting Reactions. FRONTIERS IN ALLERGY 2021; 2:727776. [PMID: 35387042 PMCID: PMC8974678 DOI: 10.3389/falgy.2021.727776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 07/30/2021] [Indexed: 11/24/2022] Open
Abstract
Insect stings and the resulting itch are a ubiquitous problem. Stings by members of the insect order Hymenoptera, which includes sawflies, wasps, bees and ants, and especially by bees and wasps are extremely common, with 56–94% of the population being stung at least once in their lifetime. The complex process of venom activity and inflammation causes local reactions with pain and pruritus, sometimes anaphylactic reactions and more seldomly, as in case of numerous stings, systemic intoxication. We reviewed the literature regarding itch experienced after Hymenoptera stings, but found no study that placed a specific focus on this topic. Hymenoptera venoms are composed of many biologically active substances, including peptide toxins and proteinaceous toxins. Peptide toxins from bee venom cause cell lysis and ion channel modulation in the peripheral and central nervous systems, while toxins from wasp venom induce mast cell degranulation and chemotaxis of polymorphonuclear leukocytes in the skin. The proteinaceous toxins cause a disruption of the cell membranes and necrotic cell death, degradation of hyaluronan (an extracellular matrix glycosaminoglycan), increased vascular permeability, hemolysis, as well as activated platelet aggregation. Mediators which could be directly involved in the venom-induced pruritus include histamine and tryptase released from mast cells, interleukin-4 and interleukin-13 from Th2 lymphocytes, as well as leukotriene C4. We postulate that a pruriceptive itch is induced due to the pharmacological properties of Hymenoptera venoms.
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Abstract
PURPOSE OF REVIEW To evaluate the indication to perform venom immunotherapy (VIT) during pregnancy considering the risks of adverse events during the build-up phase or the maintenance phase and analyzing specific articles and guidelines on VIT. RECENT FINDINGS Only few studies treat this argument and literature only counts one recent study on the topic, whereas recent guidelines state the behavior to keep in pregnancy. SUMMARY Hymenoptera venom allergy (HVA) affects about 7.5% of the European population. VIT is the only effective disease-modifying treatment for patients presenting anaphylactic reactions. VIT counts several mechanisms of action, with the increase of IgG1 and IgG4 and a cytokine impairment inducing a Th2-Th1 shift. Pregnancy is a health condition where a Th2 profile is required to prevent fetal rejection, so VIT could be a problem for the fetus when started during pregnancy.
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21
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Burzyńska M, Piasecka-Kwiatkowska D. A Review of Honeybee Venom Allergens and Allergenicity. Int J Mol Sci 2021; 22:ijms22168371. [PMID: 34445077 PMCID: PMC8395074 DOI: 10.3390/ijms22168371] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/15/2022] Open
Abstract
Honeybee venom is a source of proteins with allergenic properties which can result in in various symptoms, ranging from local reactions through to systematic life-threatening anaphylaxis, or even death. According to the World Allergy Organization (WAO), honeybee venom allergy is one of the most common causes of anaphylaxis. Among the proteins present in honeybee venom, 12 protein fractions were registered by the World Health Organization’s Allergen Nomenclature Sub-Committee (WHO/IUIS) as allergenic. Most of them are highly immunogenic glycoproteins that cross-react with IgE and, as a consequence, may give false positive results in allergy diagnosis. Allergenic fractions are different in terms of molecular weight and biological activity. Eight of these allergenic fractions have also been identified in honey. This explains frequent adverse reactions after consuming honey in people allergic to venom and sheds new light on the causes of allergic symptoms in some individuals after honey consumption. At the same time, it also indicates the possibility of using honey as a natural source of allergen in specific immunotherapy.
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22
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Luskin KT, White AA, Lyons JJ. The Genetic Basis and Clinical Impact of Hereditary Alpha-Tryptasemia. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2235-2242. [PMID: 33744473 DOI: 10.1016/j.jaip.2021.03.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 12/11/2022]
Abstract
Hereditary alpha-tryptasemia (HαT) is an autosomal dominant genetic trait found in 4% to 6% of the general population and defined by excess copies of alpha-tryptase at TPSAB1. Elevated basal serum tryptase (sBT >8 ng/mL) is a defining feature of HαT and appears to result from increased pro-alpha-tryptase synthesis and secretion rather than mast cell activation. It is estimated that approximately one-third of individuals with HαT have associated symptoms, including cutaneous, gastrointestinal, atopic, musculoskeletal, autonomic, and neuropsychiatric manifestations. HαT is found at a disproportionately high rate in systemic mastocytosis and idiopathic anaphylaxis, and is a modifying factor that independently increases the incidence and severity of anaphylaxis. The varied phenotypes associated with HαT may, in part, result from coinheritance of other genetic variants, increased expression of α-/ß-tryptase heterotetramers, and/or overexpression of pro-alpha-tryptase, although further studies are needed. There is an accurate diagnostic test available to confirm HαT in patients that can be used in combination with sBT to help risk-stratify individuals in whom bone marrow biopsy is being considered. There is no specific treatment for symptoms associated with HαT, and management is focused on controlling clinical manifestations with mast cell mediator antagonists, aspirin, inhalers, epinephrine, omalizumab, and involvement of other specialists.
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Affiliation(s)
- Kathleen T Luskin
- Division of Allergy, Asthma and Immunology, Scripps Clinic, La Jolla, Calif.
| | - Andrew A White
- Division of Allergy, Asthma and Immunology, Scripps Clinic, La Jolla, Calif
| | - Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md.
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23
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Abstract
PURPOSE OF REVIEW This review describes improvement in diagnostic accuracy, prediction of outcomes, identifying high-risk factors, and refinements of treatment that continue to evolve over the past 5-10 years. RECENT FINDINGS The risk of anaphylaxis is relatively low (< 5%) in patients with previous large local reactions or strictly cutaneous systemic reactions, but much higher in those with moderate-to-severe anaphylaxis (40%-70%) or mastocytosis (> 90%). Use of recombinant venom allergens and basophil activation tests may improve diagnostic accuracy. Elevated serum tryptase (and possible mastocytosis) occurs in 10% of patients with insect sting allergy, and in 25% of those with hypotensive reactions. Rush VIT is proven safe and rapidly effective. There are known high-risk factors that justify treatment beyond 5 years. Diagnostic accuracy and prediction of risk have improved in recent years. There are still knowledge gaps related to prediction and management of risk with current diagnostic and therapeutic modalities.
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24
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Blank S, Grosch J, Ollert M, Bilò MB. Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes. Front Immunol 2020; 11:579409. [PMID: 33193378 PMCID: PMC7643016 DOI: 10.3389/fimmu.2020.579409] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/29/2020] [Indexed: 12/12/2022] Open
Abstract
Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.
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Affiliation(s)
- Simon Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Johannes Grosch
- Center of Allergy and Environment (ZAUM), Technical University of Munich, School of Medicine and Helmholtz Center Munich, German Research Center for Environmental Health, Member of the German Center of Lung Research (DZL), Munich, Germany
| | - Markus Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
| | - Maria Beatrice Bilò
- Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy.,Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
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Bergmann-Hug K, Fricker M, Hausmann O, Helbling A, Jörg L. Sensitization to Hymenoptera venom in pollen allergic patients: Frequency and involvement of cross-reacting carbohydrate determinants (CCD). PLoS One 2020; 15:e0238740. [PMID: 32898145 PMCID: PMC7478646 DOI: 10.1371/journal.pone.0238740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/21/2020] [Indexed: 01/26/2023] Open
Abstract
Sensitization to Hymenoptera venom in patients without a history of systemic allergic reactions to Hymenoptera stings is frequently found and can be due to the presence of specific IgE to cross-reactive carbohydrate determinants (CCD). This study investigates 105 pollen allergic subjects for the presence of specific IgE to honeybee or wasp venom, pollen, the MUXF3 carbohydrate epitope from bromelain and recombinant Hymenoptera venom components. In addition, in a subgroup of patients (n = 10) a basophil activation test (BAT) using bee and wasp venom was performed. Specific IgE to Hymenoptera venom was detected in 45.7% of the pollen allergic subjects and in 26.7% of the non-atopic controls, both without a history of systemic allergic reactions to Hymenoptera stings. The high sensitization rate in atopic patients could partially be explained by cross-sensitization between pollen and Hymenoptera venom due to specific IgE to CCDs. In our study population, only 20% showed a sensitization to CCDs. Primary sensitization due to sting exposure, high total IgE values or unspecific binding and detection of low affinity antibodies in the test procedure could be reasons. Thus, determination of specific IgE to Hymenoptera venom in patients without a history of systemic allergic reactions as screening test is not recommended.
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Affiliation(s)
- Katrin Bergmann-Hug
- Allergy Unit, Zieglerspital, Clinic of Internal Medicine, Spital Netz Bern AG, Bern, Switzerland
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Fricker
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Praxisgemeinschaft Mörigen, Mörigen, Switzerland
| | - Oliver Hausmann
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ADR-AC GmbH, Adverse Drug Reactions, Analysis and Consulting, Bern, Switzerland
- Löwenpraxis Luzern, Lucerne, Switzerland
| | - Arthur Helbling
- Allergy Unit, Zieglerspital, Clinic of Internal Medicine, Spital Netz Bern AG, Bern, Switzerland
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Jörg
- Department of Rheumatology, Immunology and Allergology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- * E-mail:
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Abstract
PURPOSE OF REVIEW Information on the natural history of hypersensitivity reactions is helpful for deciding which patient urgently needs a venom immunotherapy (VIT). RECENT FINDINGS The frequency of self-reported systemic allergic reactions (SAR) to Hymenoptera stings is approximately 3-7% in the Northern Hemisphere. About 25% of SAR are severe (anaphylactic shock). Fatal sting reactions are very rare. The most important risk factor for severe insect sting anaphylaxis is mast cell disease. Other risk factors are higher age, vespid venom allergy (in contrast to honeybee venom allergy), repeated stings, male sex, and treatment with ACE inhibitors. Preceding large local reactions seem not to play a risk factor for subsequent SAR. SUMMARY The majority of risk factors for severe anaphylaxis are not modifiable. For patients presenting with well defined risk factors for a very severe or even fatal anaphylaxis, VIT is of utmost importance, and they should be performed for the rest of their life. Sting challenge tests are required to identify patients in whom treatment was ineffective. Those patients, who did not receive VIT although presenting with a firm indication, or in whom VIT was stopped, require yearly monitoring to teach preventive measures and to renew the emergency kit.
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Abstract
PURPOSE OF REVIEW Aim of this review is the description of the medical conditions in which the support of molecular allergy diagnostics (MAD) has an impact on the clinical outcomes, such as laboratory diagnostics, prognosis, and therapy of allergic diseases. RECENT FINDINGS The review of the literature of the last 2 years generated a wide number of results on this topic. As expected, not all were obtained by the use of MAD, but, in general, a clear trend is evident. SUMMARY Within the large number of works available, laboratory allergy diagnostics seems to be the most frequently discussed topic, in particular considering the complexity of the biological environment where these assays are used. Some interesting news arrive from the prognostic potential of MAD, whereas for allergen immunotherapy, waiting for a well-conducted prospective randomized clinical study, data from retrospective studies still confirms the added values of MAD in the management of the allergic patients.
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Allergic Anaphylactic Risk in Farming Activities: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144921. [PMID: 32650469 PMCID: PMC7399996 DOI: 10.3390/ijerph17144921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 12/23/2022]
Abstract
Allergic disorders in the agriculture sector are very common among farm workers, causing many injuries and occupational diseases every year. Agricultural employees are exposed to multiple conditions and various allergenic substances, which could be related to onset of anaphylactic reactions. This systematic review highlights the main clinical manifestation, the allergens that are mostly involved and the main activities that are usually involved. This research includes articles published on the major databases (PubMed, Cochrane Library, Scopus), using a combination of keywords. The online search yielded 489 references; after selection, by the authors, 36 articles (nine reviews and 27 original articles) were analyzed. From this analysis, the main clinical problems that were diagnosed in this category were respiratory (ranging from rhinitis to asthma) and dermatological (eczema, dermatitis, hives) in nature, with a wide symptomatology (from a simple local reaction to anaphylaxis). The main activities associated with these allergic conditions are harvesting or cultivation of fruit and cereals, beekeepers and people working in greenhouses. Finally, in addition to the allergens already known, new ones have emerged, including triticale, wine, spider and biological dust. For these reasons, in the agricultural sector, research needs to be amplified, considering new sectors, new technologies and new products, and ensuring a system of prevention to reduce this risk.
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Pansare M, Seth D, Kamat A, Kamat D. Summer Buzz: All You Need to Know about Insect Sting Allergies. Pediatr Rev 2020; 41:348-356. [PMID: 32611799 DOI: 10.1542/pir.2018-0358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Insect stings can generate a range of immune and clinical reactions. Most reactions are local and self-limiting. Allergic reactions to insect stings can occur at all ages, with or without previous stings. Individuals with a history of anaphylaxis carry a significant risk of life-threatening anaphylaxis with future stings. Health-care providers are often unaware of the tremendous clinical benefits of venom immunotherapy for these select patients. Scientific knowledge about the natural history, risk factors, and optimal therapy for insect sting allergies has improved considerably in recent years.
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Affiliation(s)
| | - Divya Seth
- Children's Hospital of Michigan, Detroit, MI
| | - Aarti Kamat
- Helen Devos Children's Hospital, Grand Rapids, MI
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Tripolt P, Arzt-Gradwohl L, Čerpes U, Laipold K, Binder B, Sturm GJ. Large local reactions and systemic reactions to insect stings: Similarities and differences. PLoS One 2020; 15:e0231747. [PMID: 32298380 PMCID: PMC7162517 DOI: 10.1371/journal.pone.0231747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/31/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Large local reactions (LLR) to Hymenoptera stings were considered as IgE-mediated late-phase inflammatory reactions. However, in older studies, most patients with LLR were skin test positive, but only around 50% had detectable sIgE determined by the RAST system. METHODS Data of 620 patients were evaluated retrospectively: 310 patients who suffered from LLR and 310 patients with previous systemic sting reactions (SSR). We aimed to clarify if sIgE can generally be detected by the CAP system in patients with LLR; sIgE levels and clinical parameters were compared between patients with LLR and SSR. RESULTS Positive sIgE levels were detected in 80.7% of patients with LLR, and in 95.2% of patients with SSR (p<0.001). Of the 310 patients with LLR, 80.6% had a LLR with a size of 10-20cm, whereas 19.4% had swellings >20cm, with a mean duration of seven days. In only 2.9% of patients, LLRs occurred after stings on the trunk, while 14.8% of SSR resulted from stings on this site (p<0.001). Similarly, LLR were also less frequent on the capillitium compared to SSR (8.1% versus 26.2%; p = 0.035). CONCLUSIONS LLR usually persisted over seven days and about one fifth of patients had swellings greater than 20cm. Contrary to SSR, LLR were less frequently observed on the capillitium and on the trunk. In most patients with LLR, sIgE could be detected. However, total IgE and sIgE levels to bee or vespid venom did not differ between patients with LLR and SSR.
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Affiliation(s)
- Patrik Tripolt
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Urban Čerpes
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Karin Laipold
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Barbara Binder
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
| | - Gunter Johannes Sturm
- Department of Dermatology and Venerology, Medical University of Graz, Graz, Austria
- Allergy Outpatient Clinic Reumannplatz, Vienna, Austria
- * E-mail:
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Poziomkowska-Gęsicka I, Kurek M. Clinical Manifestations and Causes of Anaphylaxis. Analysis of 382 Cases from the Anaphylaxis Registry in West Pomerania Province in Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2787. [PMID: 32316622 PMCID: PMC7215547 DOI: 10.3390/ijerph17082787] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/11/2020] [Accepted: 04/15/2020] [Indexed: 12/19/2022]
Abstract
Anaphylaxis is most commonly defined as an acute, severe, potentially life-threatening systemic hypersensitivity reaction. Current expert consensus has defined anaphylaxis as a serious reaction that is rapid in onset and can be fatal, and is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes of this reaction. There are no data from other health care centres in Poland presenting characteristics of anaphylactic reactions. Clinical manifestations of anaphylaxis should be analysed, because some patients (10-30%) with anaphylaxis can present without cutaneous findings. This lack of skin/mucosa involvement can lead to misdiagnosis or delayed diagnosis of anaphylaxis. Objectives-to gather epidemiological data on anaphylactic reactions, to identify clinical manifestations of anaphylaxis (organ systems involved), to present diagnostic methods useful for the identification of anaphylaxis triggers, and most importantly, to find causes of anaphylaxis. In this retrospective analysis, we used a questionnaire-based survey regarding patients visiting the Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, between 2006 and 2015. The registry comprised patients with grade II (Ring and Messmer classification) or higher anaphylaxis. Patients with grade I anaphylaxis (e.g., urticaria) were not included in the registry. The incidence of anaphylaxis was higher in women. Clinical manifestations included cutaneous and cardiovascular symptoms, but more than 20% of patients did not present with cutaneous symptoms, which may create difficulties for fast and correct diagnosis. Causes of anaphylaxis were identified and confirmed by means of detailed medical interview, skin tests (STs), and measurement of specific immunoglobulin E (sIgE) and tryptase levels. In the analysed group, the most common cause of anaphylaxis (allergic and nonallergic) was Hymenoptera stinging (wasp), drugs (nonsteroidal anti-inflammatory drugs, NSAIDs) and foods (peanuts, tree nuts, celery). The incidence of anaphylaxis is low, but because of its nature and potentially life-threatening consequences it requires a detailed approach. Comprehensive management of patients who have had anaphylaxis can be complex, so partnerships between allergy specialists, emergency medicine and primary care providers are necessary. Monitoring its range is very important to monitor changes in allergy development.
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Affiliation(s)
- Iwona Poziomkowska-Gęsicka
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, Powstańców Wlkp 72, 70-111 Szczecin, Poland;
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Antolín-Amérigo D, Ruiz-León B, Vega-Castro A, de la Hoz Caballer B. Natural history of systemic reactions and risk factors in children and adults with Hymenoptera venom allergy. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-0745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Gruzelle V, Mailhol C, Waters DW, Guilleminault L. Clinical Utility of Rush Venom Immunotherapy: Current Status. J Asthma Allergy 2020; 13:1-10. [PMID: 32021308 PMCID: PMC6954838 DOI: 10.2147/jaa.s200917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/03/2019] [Indexed: 11/29/2022] Open
Abstract
Hymenoptera venom allergy (HVA) is the leading cause of anaphylactic reactions in adults and the second most common cause in children. Venom immunotherapy (VIT) is used to elicit an immune tolerance against hymenoptera venom in allergic patients and is based on the administration of purified venom extracts regularly for defined periods. The protocols of administration include 2 phases: an up-dosing phase that incrementally reaches the final dose resulting in a protective effect, and a maintenance phase in order to obtain the sustained effect. The goal of this review is to detail the efficacy and the safety of the up-dosing phase also named rush. Pathophysiological mechanisms, indications of VIT and technical aspects of up-dosing protocol are also covered.
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Affiliation(s)
- Vianney Gruzelle
- Department of Paediatric Pneumology and Allergology, University Hospital Centre of Toulouse, Toulouse, France
| | - Claire Mailhol
- Department of Respiratory Medicine and Allergic Diseases, University Hospital Centre of Toulouse, Toulouse, France.,Mastocytosis Reference Centre and Dermatology Department, University Hospital Centre of Toulouse, Toulouse, France
| | - David W Waters
- Center for Pathophysiology Toulouse Purpan, INSERM U1043, CNRS UMR 5282, Toulouse III University, Toulouse, France
| | - Laurent Guilleminault
- Department of Respiratory Medicine and Allergic Diseases, University Hospital Centre of Toulouse, Toulouse, France.,Center for Pathophysiology Toulouse Purpan, INSERM U1043, CNRS UMR 5282, Toulouse III University, Toulouse, France
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Abstract
Stinging insect allergy is uncommon but can be life threatening. Diagnosis requires clinical history and confirmative skin or blood testing by an allergist. Baseline serum tryptase level can be used to stratify risk. Treatment is supportive for all reactions except for anaphylaxis, which is treated with intramuscular epinephrine, recumbent posture, and adjunct measures such as IV fluids, and oxygen. Venom immunotherapy is most effective for long-term management in patients with a history of anaphylaxis. Venom immunotherapy rapidly reduces the risk of sting anaphylaxis by up to 98% and maintenance treatment can be stopped after 5 years in most cases.
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Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, FE125-685 William Avenue, Winnipeg, Manitoba R2A 5L9, Canada
| | - David B K Golden
- Department of Medicine, Johns Hopkins University School of Medicine, 20 Crossroads Drive Suite 16, Owings Mills, MD 21117, USA.
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Fehr D, Micaletto S, Moehr T, Schmid-Grendelmeier P. Risk factors for severe systemic sting reactions in wasp ( Vespula spp.) and honeybee ( Apis mellifera) venom allergic patients. Clin Transl Allergy 2019; 9:54. [PMID: 31632639 PMCID: PMC6788055 DOI: 10.1186/s13601-019-0292-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/21/2019] [Indexed: 11/21/2022] Open
Abstract
Background Hymenoptera stings are a major cause of anaphylaxis. Various risk factors are discussed in literature. This study aims to investigate potential risk factors for severe sting reactions in wasp (Vespula spp.) and honeybee (Apis mellifera) venom allergic patients and analyses the correlation between diagnostic test results and the severity of the allergic reaction. Methods 480 patients suffering from wasp or honeybee venom allergy were included in this retrospective case series. Only individuals allergic to Vespula spp. but not to other vespids such as Polistes were considered. The severity of their systemic field sting reaction was analysed with regard to the amount of specific IgE antibodies to whole venom extracts and to major allergens of honeybee and/or wasp venom. Furthermore, the following potential risk factors for severe sting reactions were examined: age, sex, latency time, skin symptoms, baseline serum tryptase levels and the concentration of venom inducing a positive intracutaneous test. Results The two following indicators for severe systemic sting reactions in honeybee and wasp venom allergic patients have been identified: a short latency time and the absence of skin symptoms. The patient’s age and baseline serum tryptase levels have been found to positively correlate with the grade of the sting reaction only in individuals allergic to wasp venom. No correlation could be found between the degree of sensitisation and the severity of the allergic reaction. Neither the amount of specific IgE antibodies to whole venom extracts nor to major allergens were significantly associated with the severity of the sting reaction. Conclusion The clinical history is essential for the allergological workup and therapeutic decision on Hymenoptera venom allergies. A short latency time and the absence of skin symptoms are indicators for severe systemic sting reactions, followed by the patient’s age and baseline serum tryptase levels.
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Affiliation(s)
- Danielle Fehr
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
| | - Sara Micaletto
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
| | - Thomas Moehr
- B,S,S. Economic Consultants, Aeschengraben 9, 4051 Basel, Switzerland
| | - Peter Schmid-Grendelmeier
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
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Bilò MB, Martini M, Pravettoni V, Bignardi D, Bonadonna P, Cortellini G, Kosinska M, Macchia D, Mauro M, Meucci E, Nittner‐Marszalska M, Patella V, Pio R, Quercia O, Reccardini F, Ridolo E, Rudenko M, Severino M. Large local reactions to Hymenoptera stings: Outcome of re-stings in real life. Allergy 2019; 74:1969-1976. [PMID: 31074868 DOI: 10.1111/all.13863] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/08/2019] [Accepted: 04/11/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Large local reaction to Hymenoptera stings is usually defined as a swelling >10 cm which lasts longer than 24 hours, sometimes associated with erythema, pruritus and blisters. Currently, the risk of subsequent systemic reactions after re-stings is considered low (2%-15%). Therefore, a diagnostic workup in case of large local reaction is often judged unnecessary, as well as adrenaline auto-injector and venom immunotherapy prescription. The aim of this study was to prospectively evaluate the outcome of re-stings in a real-world setting, in patients with a history of one previous large local reaction. METHODS We consecutively enrolled patients who experienced their first large local reaction (as per EAACI definition), treated with antihistamine and steroids. They were followed for field re-stings and assessed for risk of subsequent systemic reactions. RESULTS We enrolled 662 patients. Out of the 225 re-stung subjects, 24% did not experience reactions, 52% reported a second large local reaction and 24% had systemic reactions. The risk of subsequent systemic reactions was higher in case of skin test reactivity to Apis mellifera or Vespula species (OR 2.1 and 3.8, respectively), in particular if positive at 0.001 µg/mL concentration (OR 13.4 and 16.5, respectively). CONCLUSIONS Systemic reactions, after a previous large local reaction, occur more frequently than that reported by literature. After analysing the predictive role of large local reactions for systemic reactions, we demonstrated that an accurate diagnostic workup may be considered, particularly skin tests. Further studies in different countries are needed to confirm these results and large local reaction management.
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Affiliation(s)
- Maria Beatrice Bilò
- Allergy Unit, Department of Clinical and Molecular Sciences Università Politecnica delle Marche Ancona Italy
| | - Matteo Martini
- Allergy and Clinical Immunology School Università Politecnica delle Marche Ancona Italy
| | - Valerio Pravettoni
- General Medicine, Immunology and Allergy Unit ‐ IRCCS Foudation Ca’ Granda Ospedale Maggiore Policlinico Milan Italy
| | | | - Patrizia Bonadonna
- U.S.D. Allergology Integrated University‐Hospital of Verona Verona Italy
| | - Gabriele Cortellini
- Allergy Unit, Internal Medicine Department, Rimini Hospital Local Health Unit of Romagna Rimini Italy
| | - Magdalena Kosinska
- Department of Internal Diseases and Allergology Medical University of Wroclaw Wroclaw Poland
| | | | - Marina Mauro
- UOS Allergology ASST Lariana Sant'Anna Hospital Como Italy
| | - Elisa Meucci
- Allergy Unit, Hospital S. Giovanni di Dio Florence Italy
| | | | - Vincenzo Patella
- Division Allergy and Clinical Immunology, Department of Medicine ASL Salerno "Santa Maria della Speranza" Hospital Salerno Italy
| | - Roberta Pio
- A.O.U San Giovanni di Dio e Ruggi d'Aragona Salerno Italy
| | - Oliviero Quercia
- High Specialization Unit of Allergology, Hospital of Faenza AUSL (Local Health Unit) of Romagna Faenza Italy
| | - Federico Reccardini
- SOC Pneumologia‐Fisiopatologia Respiratoria, Azienda Sanitaria Universitaria Integrata di Udine Udine Italy
| | - Erminia Ridolo
- Allergologia e Immunologia Clinica, Dipartimento di Medicina e Chirurgia Università degli studi di Parma Parma Italy
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Pucci S, Incorvaia C, Romano A. Large local reaction to Hymenoptera stings: Sound studies are needed to change a shared concept. IMMUNITY INFLAMMATION AND DISEASE 2019; 7:258-259. [PMID: 31493336 PMCID: PMC6842820 DOI: 10.1002/iid3.268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 07/02/2019] [Accepted: 07/20/2019] [Indexed: 11/09/2022]
Abstract
The natural history of large local reactions to Hymenoptera stings allowed to estimate the risk to develop a systemic reaction after an initial large local reaction in about 4% of patients. A recently published study claimed that such risk concerns instead around one-fourth of patients. However, such study is flawed by serious imprecision, particularly the unreliable identification by patients of the culprit insect, as well as the dubious identification of the causative venom in multisensitized patients. Also, the authors criticized previous studied because of the limited number of patients, while they included in the study 662 patients. Indeed, when only patients clearly restung by the same insect according to their history data were considered, the number of patients fell to 35. These data are unable to change the current shared concept on the low risk of systemic reactions in patients with initial large local reaction.
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Affiliation(s)
- Stefano Pucci
- General Hospital Civitanova Marche, Allergy Unit, Civitanova Marche, Italy
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Zink A, Schuster B, Winkler J, Eyerich K, Darsow U, Brockow K, Eberlein B, Biedermann T. Allergy and sensitization to Hymenoptera venoms in unreferred adults with a high risk of sting exposure. World Allergy Organ J 2019; 12:100039. [PMID: 31312341 PMCID: PMC6610241 DOI: 10.1016/j.waojou.2019.100039] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/16/2019] [Accepted: 05/17/2019] [Indexed: 12/01/2022] Open
Abstract
Background Hymenoptera venom sensitization in highly exposed individuals frequently requires risk assessment for future severe sting reactions. In this study, we determined the prevalence of Hymenoptera venom sensitization in individuals who hunt and fish and analyzed possible correlations between the severity of sting reactions and the IgE sensitization profile. Methods In this cross-sectional study, paper-based, self-filled questionnaires about previous insect stings and sting reactions were obtained from individuals who hunt and fish in Bavaria, Germany. Blood samples were taken and analyzed for the levels of tryptase, total IgE and IgE to honey bee (i1) and wasp (13) venom, the recombinant allergens rApi m 1, rApi m 2, rApi m 3, rApi m 5, rApi m 10, rVes v 1, rVes v 5, and the CCD marker molecule MUXF3. Odd ratios (ORs) for sensitization and anaphylaxis and Pearson's correlations for the different allergens were calculated. Results Of 257 participants, 50.2% showed a sensitization to honey bee venom (i1), and 58.4% showed sensitization to wasp venom (i3). A total of 98.4% of participants claimed to have been stung at least once. Anaphylaxis was reported in 18.7%, and a local sting reaction was reported in 18.3%. The highest sensitization rates were found for whole venom extracts, sensitization to any of the available recombinant allergens exceeded sIgE levels to honeybee venom (i1) in 28.5% and to wasp venom (i3) in 52.9% of participants. Participants with a history of more than 5 stings showed a higher risk for anaphylaxis. Conclusions Sensitization to Hymenoptera venom and their recombinant allergens are present in the majority of individuals who hunt and fish. Sensitization to distinct recombinant allergens does not necessarily affect the severity of sting reactions including anaphylaxis. A meticulous medical history of the number of previous stings as well as systemic reactions remains essential.
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Affiliation(s)
- Alexander Zink
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Barbara Schuster
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Julia Winkler
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Kilian Eyerich
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Ulf Darsow
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Bernadette Eberlein
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Tilo Biedermann
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
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Bokanovic D, Arzt-Gradwohl L, Schwarz I, Schrautzer C, Laipold K, Aberer W, Binder B, Sturm GJ. Possible utility of basophil activation test in dual honeybee and vespid sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:392-394.e5. [PMID: 31233939 DOI: 10.1016/j.jaip.2019.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/03/2019] [Accepted: 06/11/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Danijela Bokanovic
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Lisa Arzt-Gradwohl
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Ines Schwarz
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Christoph Schrautzer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Karin Laipold
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Werner Aberer
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Barbara Binder
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - Gunter J Sturm
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria; Allergy Outpatient Clinic Reumannplatz, Vienna, Austria.
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Sin BA, Tutkak H, Birben E, Köse K, Mısırlıgil Z. Cytokine genes show distinct polymorphism pattern in Hymenoptera venom allergy. Allergy 2019; 74:1020-1022. [PMID: 30592056 DOI: 10.1111/all.13706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Betül Ayşe Sin
- Division of Immunology & Allergy School of Medicine Ankara University Ankara Turkey
| | - Hüseyin Tutkak
- Immunology Laboratory School of Medicine Ankara University AnkaraTurkey
| | - Esra Birben
- Pediatric Allergy and Asthma Unit School of Medicine Hacettepe University AnkaraTurkey
| | - Kenan Köse
- Department of Biostatistics School of Medicine Ankara University AnkaraTurkey
| | - Zeynep Mısırlıgil
- Division of Immunology & Allergy School of Medicine Ankara University Ankara Turkey
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Kukkonen AK, Pelkonen AS, Edelman SM, Kauppi PM, Mäkelä MJ. Component-resolved diagnosis in selecting patients for yellowjacket venom immunotherapy. Ann Allergy Asthma Immunol 2019; 120:184-189. [PMID: 29413342 DOI: 10.1016/j.anai.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/03/2017] [Accepted: 11/14/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Venom immunotherapy is effective in preventing systemic allergic reactions (SARs), but the diagnosis of venom allergy is problematic. OBJECTIVE To compare the performance of component-resolved diagnosis and conventional tests in patients referred for venom immunotherapy. METHODS We measured serum-specific immunoglobulin E to yellowjacket and honeybee venoms (Ves v 1 and Ves v 5 and Api m 1), cross-reactive carbohydrate determinants, serum basal tryptase (ImmunoCAP, ThermoFisher Scientific, Uppsala, Sweden), and skin prick test reactions in 84 patients referred to receive venom immunotherapy. History of SAR and its severity were evaluated. RESULTS Of the 78 patients with suspected yellowjacket venom (YJV) allergy, a history of SAR was confirmed in 47 (60%) and 31 (40%) had a non-SAR reaction. The most accurate tests to confirm venom allergy after a SAR were serum-specific immunoglobulin E to yellowjacket whole-venom extract spiked with Ves v 5 (area under the curve 0.87, 95% confidence interval 0.77-0.97, P < .001) and Ves v 5 (area under the curve 0.86, 95% confidence interval 0.76-0.96, P < .001). Sensitization to Ves v 1 was infrequent and its area under the curve was low (0.62, 95% confidence interval 0.47-0.76, P = .106). Sensitivity of the YJV skin prick test was 86%, but its specificity was low at 54%. Double sensitization to yellowjacket and honeybee occurred frequently in skin prick tests. Of the patients without a SAR, 26% showed a positive reaction to YJV in any serum test and 46% showed a positive reaction in skin tests. CONCLUSION Specific immunoglobulin E to the YJV spiked with Ves v 5 confirmed the allergy after a SAR. A history of SAR should be confirmed before testing, because venom sensitization is frequent in other types of reactions.
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Affiliation(s)
- Anna Kaarina Kukkonen
- University of Helsinki and Helsinki University Skin and Allergy Hospital, Helsinki, Finland.
| | - Anna Susanna Pelkonen
- University of Helsinki and Helsinki University Skin and Allergy Hospital, Helsinki, Finland
| | - Sanna Marika Edelman
- University of Helsinki and Helsinki University Skin and Allergy Hospital, Helsinki, Finland
| | - Paula Maria Kauppi
- University of Helsinki and Helsinki University Skin and Allergy Hospital, Helsinki, Finland
| | - Mika Juhani Mäkelä
- University of Helsinki and Helsinki University Skin and Allergy Hospital, Helsinki, Finland
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Helbling A, Müller UR. Allergic Reactions to Stinging and Biting Insects. Clin Immunol 2019. [DOI: 10.1016/b978-0-7020-6896-6.00043-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Stoevesandt J, Hosp C, Kerstan A, Trautmann A. Sensitization to
Hymenoptera
venom marker allergens: Prevalence, predisposing factors, and clinical implications. Clin Exp Allergy 2018; 48:1735-1743. [DOI: 10.1111/cea.13237] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 07/13/2018] [Accepted: 07/15/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Johanna Stoevesandt
- Department of Dermatology, Venereology, and Allergology University Hospital Würzburg Würzburg Germany
| | - Christine Hosp
- Department of Dermatology, Venereology, and Allergology University Hospital Würzburg Würzburg Germany
| | - Andreas Kerstan
- Department of Dermatology, Venereology, and Allergology University Hospital Würzburg Würzburg Germany
| | - Axel Trautmann
- Department of Dermatology, Venereology, and Allergology University Hospital Würzburg Würzburg Germany
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Bonadonna P, Scaffidi L. Hymenoptera Anaphylaxis as a Clonal Mast Cell Disorder. Immunol Allergy Clin North Am 2018; 38:455-468. [DOI: 10.1016/j.iac.2018.04.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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45
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Lyons JJ. Hereditary Alpha Tryptasemia: Genotyping and Associated Clinical Features. Immunol Allergy Clin North Am 2018; 38:483-495. [PMID: 30007465 DOI: 10.1016/j.iac.2018.04.003] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hereditary alpha tryptasemia is an autosomal dominant genetic trait caused by increased germline copies of TPSAB1 encoding alpha-tryptase. Individuals with this trait have elevated basal serum tryptase, and may present with associated multisystem complaints. Both basal serum tryptase levels and severity of clinical symptoms display a gene-dose relationship with TPSAB1, whereby higher tryptase levels and greater symptom severity are correlated with increasing numbers of alpha-encoding TPSAB1. As the functional effects of increased basal serum tryptase and/or altered tryptase gene expression are elucidated, greater insights will be gained into the symptoms associated with hereditary alpha tryptasemia and their potential therapy.
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Affiliation(s)
- Jonathan J Lyons
- Laboratory of Allergic Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Building 10, Room 11N240 MSC 1889, 10 Center Drive, Bethesda, MD 20892, USA.
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Arzt L, Bokanovic D, Schrautzer C, Laipold K, Möbs C, Pfützner W, Herzog SA, Vollmann J, Reider N, Bohle B, Aberer W, Sturm GJ. Immunological differences between insect venom-allergic patients with and without immunotherapy and asymptomatically sensitized subjects. Allergy 2018; 73:1223-1231. [PMID: 29171032 DOI: 10.1111/all.13368] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Currently available tests are unable to distinguish between asymptomatic sensitization and clinically relevant Hymenoptera venom allergy. A reliable serological marker to monitor venom immunotherapy (VIT) does also not exist. Our aim was to find reliable serological markers to predict tolerance to bee and vespid stings. METHODS We included 77 asymptomatically sensitized subjects, 85 allergic patients with acute systemic sting reactions, and 61 allergic patients currently treated with VIT. Levels of sIgE and sIgG4 to bee and vespid venom, rApi m 1, and rVes v 5 were measured immediately after allergic sting reactions or before sting challenges and 4 weeks later. All sting challenges were tolerated. The inhibitory activity was determined using BAT inhibition and ELIFAB assay. RESULTS Median sIgG4 levels were 96-fold higher in VIT patients (P < .001) while sIgE/sIgG4 ratios were consistently lower (P < .001). The ELIFAB assay was paralleled by low sIgE/sIgG4 ratios in VIT patients, showing markedly higher allergen-blocking capacity (P < .001). An almost complete inhibition of the basophil response was seen in all patients treated with vespid venom, but not in those treated with bee venom. Four weeks after the sting, sIgE and sIgG4 levels were increased in allergic and asymptomatically sensitized patients, but not in VIT patients. CONCLUSION Immunological responses after stings varied in bee and vespid venom-allergic patients. In patients under VIT, sIgE and sIgG4 remained completely stable after sting challenges. Monitoring VIT efficacy was only possible in vespid venom allergy, and the sIgG4 threshold for rVes v 5 had the highest sensitivity to confirm tolerance. The BAT inhibition test was the most reliable tool to confirm tolerance on an individual basis.
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Affiliation(s)
- L. Arzt
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - D. Bokanovic
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - C. Schrautzer
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - K. Laipold
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - C. Möbs
- Clinical & Experimental Allergology, Department of Dermatology and Allergology Philipps‐University of Marburg Marburg Germany
| | - W. Pfützner
- Clinical & Experimental Allergology, Department of Dermatology and Allergology Philipps‐University of Marburg Marburg Germany
| | - S. A. Herzog
- Institute for Medical Informatics, Statistics and Documentation Medical University of Graz Graz Austria
| | - J. Vollmann
- Institute of Zoology University of Graz Graz Austria
| | - N. Reider
- Department of Dermatology, Venerology and Allergology Medical University of Innsbruck Innsbruck Austria
| | - B. Bohle
- Division of Cellular Allergology Institute of Pathophysiology and Allergy Research Medical University of Vienna Vienna Austria
| | - W. Aberer
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
| | - G. J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
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Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, Antolín-Amérigo D, Cichocka-Jarosz E, Gawlik R, Jakob T, Kosnik M, Lange J, Mingomataj E, Mitsias DI, Ollert M, Oude Elberink JNG, Pfaar O, Pitsios C, Pravettoni V, Ruëff F, Sin BA, Agache I, Angier E, Arasi S, Calderón MA, Fernandez-Rivas M, Halken S, Jutel M, Lau S, Pajno GB, van Ree R, Ryan D, Spranger O, van Wijk RG, Dhami S, Zaman H, Sheikh A, Muraro A. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy 2018; 73:744-764. [PMID: 28748641 DOI: 10.1111/all.13262] [Citation(s) in RCA: 236] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2017] [Indexed: 01/27/2023]
Abstract
Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.
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Blank S, Bilò MB, Ollert M. Component-resolved diagnostics to direct in venom immunotherapy: Important steps towards precision medicine. Clin Exp Allergy 2018; 48:354-364. [PMID: 29331065 DOI: 10.1111/cea.13090] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Stings of Hymenoptera can induce IgE-mediated systemic and even fatal allergic reactions. Venom-specific immunotherapy (VIT) is the only disease-modifying and curative treatment of venom allergy. However, choosing the correct venom for VIT represents a necessary prerequisite for efficient protection against further anaphylactic sting reactions after VIT. In the past, therapeutic decisions based on the measurement of specific IgE (sIgE) levels to whole venom extracts were not always straightforward, especially when the patient was not able to identify the culprit insect. In the last years, the increasing knowledge about the molecular structure and relevance of important venom allergens and their availability as recombinant allergens, devoid of cross-reactive carbohydrate determinants, resulted in the development of an advanced component-resolved diagnostics (CRD) approach in venom allergy. Already to date, CRD has increased the sensitivity of sIgE detection and enabled the discrimination between primary sensitization and cross-reactivity, particularly in patients with sensitization to both honeybee and vespid venom. Hence, CRD in many patients improves the selection of the appropriate immunotherapeutic intervention. Moreover, the detailed knowledge about sensitization profiles on a molecular level might open new options to identify patients who are at increased risk of side-effects or not to respond to immunotherapy. Therefore, increasing potential of CRD becomes evident, to direct therapeutic decisions in a personalized and patient-tailored manner. Reviewed here are the state of the art options, recent developments and future perspectives of CRD of Hymenoptera venom allergy.
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Affiliation(s)
- S Blank
- Center of Allergy and Environment (ZAUM), Technical University of Munich and Helmholtz Center Munich, Munich, Germany
| | - M B Bilò
- Allergy Unit, Department of Internal Medicine, University Hospital of Ancona, Ancona, Italy
| | - M Ollert
- Department of Infection and Immunity, Luxembourg Institute of Health (LIH), Esch-sur-Alzette, Luxembourg.,Department of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, University of Southern Denmark, Odense, Denmark
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Golden DBK, Demain J, Freeman T, Graft D, Tankersley M, Tracy J, Blessing-Moore J, Bernstein D, Dinakar C, Greenhawt M, Khan D, Lang D, Nicklas R, Oppenheimer J, Portnoy J, Randolph C, Schuller D, Wallace D. Stinging insect hypersensitivity: A practice parameter update 2016. Ann Allergy Asthma Immunol 2017; 118:28-54. [PMID: 28007086 DOI: 10.1016/j.anai.2016.10.031] [Citation(s) in RCA: 140] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Hymenoptera anaphylaxis is one of the leading causes of severe allergic reactions and can be fatal. Venom-specific immunotherapy (VIT) can prevent a life-threatening reaction; however, confirmation of an allergy to a Hymenoptera venom is a prerequisite before starting such a treatment. Component resolved diagnostics (CRD) have helped to better identify the responsible allergen. RECENT FINDINGS Many new insect venom allergens have been identified within the last few years. Commercially available recombinant allergens offer new diagnostic tools for detecting sensitivity to insect venoms. Additional added sensitivity to nearly 95% was introduced by spiking yellow jacket venom (YJV) extract with Ves v 5. The further value of CRD for sensitivity in YJV and honey bee venom (HBV) allergy is more controversially discussed. Recombinant allergens devoid of cross-reactive carbohydrate determinants often help to identify the culprit venom in patients with double sensitivity to YJV and HBV. CRD identified a group of patients with predominant Api m 10 sensitization, which may be less well protected by VIT, as some treatment extracts are lacking this allergen. The diagnostic gap of previously undetected Hymenoptera allergy has been decreased via production of recombinant allergens. Knowledge of analogies in interspecies proteins and cross-reactive carbohydrate determinants is necessary to distinguish relevant from irrelevant sensitizations.
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