The renin angiotensin system and hymenoptera venom anaphylaxis

Antiviral attributes of bee venom as a possible therapeutic approach against SARS-CoV-2 infection

The unprecedented scale of the SARS-CoV-2 pandemic has driven considerable investigation into novel antiviral treatments since effective vaccination strategies cannot completely eradicate the virus. Apitherapy describes the medicinal use of bee venom, which may be an effective treatment against SARS-CoV-2 infection. Bee venom contains chemicals that are antimicrobial and stimulate the immune system to counteract viral load. The present review focuses on the use of bee venom as a possible treatment for COVID-19 and reviews studies on the pharmacodynamics of bee venom.

Medicolegal Implications of Biphasic Anaphylaxis

ABSTRACT

Biphasic anaphylaxis is an uncommon IgE-mediated condition whose pathophysiological mechanisms, risk factors, and predictive signs are not properly understood. Fortunately, the lethality of biphasic anaphylaxis, although probably underestimated, is low. Preventive clinical measures for biphasic anaphylaxis are neither standardized nor commonly applied. Furthermore, there are no laboratory protocols or anaphylactic markers to help identify the onset of biphasic anaphylaxis in clinical settings. The aim of this review is to highlight the medicolegal difficulties facing coroners and forensic pathologists in terms of the diagnosis and assessment of harm for victims and survivors of biphasic anaphylaxis.

Bee Venom-A Potential Complementary Medicine Candidate for SARS-CoV-2 Infections

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by severe cytokine storm syndrome following inflammation. SARS-CoV-2 directly interacts with angiotensin-converting enzyme 2 (ACE-2) receptors in the human body. Complementary therapies that impact on expression of IgE and IgG antibodies, including administration of bee venom (BV), have efficacy in the management of arthritis, and Parkinson's disease. A recent epidemiological study in China showed that local beekeepers have a level of immunity against SARS-CoV-2 with and without previous exposure to virus. BV anti-inflammatory properties are associated with melittin and phospholipase A2 (PLA2), both of which show activity against enveloped and non-enveloped viruses, including H1N1 and HIV, with activity mediated through antagonist activity against interleukin-6 (IL-6), IL-8, interferon-γ (IFN-γ), and tumor necrosis factor-α (TNF-α). Melittin is associated with the underexpression of proinflammatory cytokines, including nuclear factor-kappa B (NF-κB), extracellular signal-regulated kinases (ERK1/2), and protein kinase Akt. BV therapy also involves group III secretory phospholipase A₂ in the management of respiratory and neurological diseases. BV activation of the cellular and humoral immune systems should be explored for the application of complementary medicine for the management of SARS-CoV-2 infections. BV "vaccination" is used to immunize against cytomegalovirus and can suppress metastases through the PLA2 and phosphatidylinositol-(3,4)-bisphosphate pathways. That BV shows efficacy for HIV and H1NI offers opportunity as a candidate for complementary therapy for protection against SARS-CoV-2.

P-ANCA vasculitis with diffuse alveolar haemorrhage preceded by a spider bite

We report a patient with antineutrophilic cytoplasmic antibody (ANCA) vasculitis that was preceded by witnessed black widow spider bites. The patient initially presented with a diffuse painful skin rash that developed after a few hours post bite. He was treated initially with topical ointment for the suspected bite. However, subsequently a few days later the patient returned to the hospital with similar, but more progressive rash with haemoptysis and acute hypoxic respiratory failure requiring supplemental oxygen. Immunology work up showed elevated titre of peri-nuclear ANCA. Bronchoscopy revealed diffuse alveolar haemorrhage. The patient was treated successfully with methylprednisolone and rituximab.

IgE-Mediated Systemic Anaphylaxis And Its Association With Gene Polymorphisms Of ACE, Angiotensinogen And Chymase

BACKGROUND

The renin-angiotensin system (RAS) protects the circulation against sudden falls in systemic blood pressure via generation of angiotensin II (AII). Previously, we demonstrated that patients with anaphylaxis involving airway angioedema and cardiovascular collapse (AACVS) had significantly increased "I" gene polymorphisms of the angiotensin-converting-enzymes (ACE). This is associated with lower serum ACE and AII levels and was not seen in anaphylaxis without collapse nor atopics and healthy controls.

OBJECTIVES

To examine the angiotensinogen (AGT-M235T) and chymase gene (CMA-1 A1903G) polymorphisms in these original subjects.

METHOD

122 patients with IgE-mediated anaphylaxis, 119 healthy controls and 52 atopics had polymorphisms of the AGT gene and chymase gene examined by polymerase chain reactions and gel electrophoresis. Their previous ACE genotypes were included for the analysis.

RESULTS

AGT-MM genes (associated with low AGT levels) were significantly increased in anaphylaxis (Terr's classification). When combined with ACE, anaphylaxis showed increased MM/II gene pairing (p<0.0013) consistent with lower RAS activity. For chymase, there was increased pairing of MM/AG (p<0.005) and AG/II and AG/ID (p<0.0073) for anaphylaxis consistent with lower RAS activity. A tri-allelic ensemble of the 6 commonest gene combinations for the healthy controls and anaphylaxis confirmed this difference (p=0.0001); for anaphylaxis, genes were predominately MM/AG/II or ID, while healthy controls were DD/MT/AG or GG patterns.

CONCLUSION

Our gene polymorphisms show lower RAS activity for anaphylaxis especially AACVS. Animal models of anaphylaxis are focused on endothelial nitric oxide (eNO) which is shown to be the mediator of fatal shock and prevented by eNO-blockade. The interaction of AII and eNO controls the microcirculation in man. High serum AII levels reduce eNO activity, so higher RAS-activity could protect against shock. Our data shows low RAS activity in anaphylaxis especially AACVS, suggesting the influence of these genes on shock are via AII levels and its effects on eNO.

Safety and tolerability during build-up phase of a rush venom immunotherapy

BACKGROUND

Safety and tolerability of venom immunotherapy (VIT) in patients with concomitant disease and comedications, especially β-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs), are under discussion.

OBJECTIVE

To identify risk factors for the occurrence of systemic reactions (SRs) during the build-up phase of a 3-day rush VIT with focus on comorbidities and related comedications.

METHODS

Data of 175 three-day rush VIT courses (Vespula venom, n = 161; honeybee venom, n = 14) were analyzed. Starting with 0.02 μg of venom, the maintenance dose of 100 μg was reached in 15-dose increments within 3 days. Local reactions (LRs) and SRs were documented during the build-up phase. Comorbidities and related comedications were registered. Univariate, bivariate, and multivariate data analysis was performed.

RESULTS

During the 3-day rush VIT, an LR was seen in 74 (42.3%) of 175, a large LR (>10-cm diameter) in 82 (46.9%) of 175, and SRs in 19 (10.9%) of 175 VIT courses. Multivariate logistic regression revealed that female sex (P = .01), immunotherapy with honeybee venom (P = .003), and accompanying ACEI medication (P = .03) were independent predictors of the development of SRs during the build-up phase of VIT.

CONCLUSION

This study revealed that female sex, honeybee VIT, and ACEI use independent predictors for SRs.

Clinical contraindications to allergen immunotherapy: an EAACI position paper

Clinical indications for allergen immunotherapy (AIT) in respiratory and Hymenoptera venom allergy are well established; however, clinical contraindications to AIT are not always well documented. There are some discrepancies when classifying clinical contraindications for different forms of AIT as 'absolute' or 'relative'. EAACI Task Force on 'Contraindications to AIT' was created to evaluate and review current literature on clinical contraindications, and to update recommendations for both sublingual and subcutaneous AIT for respiratory and venom immunotherapy. An extensive review of the literature was performed on the use of AIT in asthma, autoimmune disorders, malignant neoplasias, cardiovascular diseases, acquired immunodeficiencies and other chronic diseases (including mental disorders), in patients treated with β-blockers, ACE inhibitors or monoamine oxidase inhibitors, in children under 5 years of age, during pregnancy and in patients with poor compliance. Each topic was addressed by the following three questions: (1) Are there any negative effects of AIT on this concomitant condition/disease? (2) Are more frequent or more severe AIT-related side-effects expected? and (3) Is AIT expected to be less efficacious? The evidence, for the evaluation of these clinical conditions as contraindications, was limited, and most of the conclusions were based on case reports. Based on an extended literature research, recommendations for each medical condition assessed are provided. The final decision on the administration of AIT should be based on individual evaluation of any medical condition and a risk/benefit assessment for each patient.

IgE-Mediated Anaphylaxis to Foods, Venom, and Drugs: Influence of Serum Angiotensin Converting Enzyme Levels and Genotype

Circulating angiotensin-II protects the circulation against sudden falls in blood pressure and is generated by the enzymatic action of angiotensin converting enzyme (ACE) on angiotensin-I. The ACE genes have 2 allelic forms, “I” and “D.” The “D” genotype has both highest angiotensin-II generation and serum ACE levels compared to “I”. 120 patients with IgE-anaphylaxis, 119 healthy controls, and 49 atopics had serum ACE levels, ACE genotype, and renin levels determined. Plasma renin levels were identical for all groups. Serum ACE levels and genotypes were similar for healthy controls (HC) and atopics, but lower in anaphylaxis (P = 0.012), with ACE genotypes also showing increased “I” genes (P = 0.009). This effect was more pronounced in subjects manifesting airway angioedema and cardiovascular collapse (AACVS) than mild cutaneous and respiratory (CRA) symptoms. AACVS was significantly associated with the presence of “I” genes. For “ID” genotype OR is 5.6, 95% CI 1.8 to 17.4, and for “II” genotype OR is 44, 95% CI 5 to 1891 within the anaphylaxis group = 0.001. The results show a difference in the genotype frequency between control and anaphylaxis, suggesting a role for the renin angiotensin system in anaphylaxis manifesting with airway angioedema and cardiovascular collapse.

Kounis syndrome: a new twist on an old disease

Kounis syndrome is the concurrence of acute coronary syndromes with conditions associated with mast cell activation, such as allergies or hypersensitivity and anaphylactic or anaphylactoid insults that can involve other interrelated and interacting inflammatory cells behaving as a 'ball of thread'. It is caused by inflammatory mediators such as neutral proteases including tryptase and chymase, arachidonic acid products, histamine, platelet activating factor and a variety of cytokines and chemokines released during the activation process. Platelets with FCεRI and FCεRII receptors also participate in the above cascade. Vasospastic allergic angina, allergic myocardial infarction and stent thrombosis with occluding thrombus infiltrated by eosinophils and/or mast cells constitute the three reported variants of this syndrome. Kounis syndrome is a ubiquitus disease that represents a magnificent natural paradigm and nature's own experiment, in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture. Kounis syndrome can complicate anesthesia, vaccination, medical therapy and stent implantation and it seems to be associated with coronary allograft vasculopathy and takotsubo syndrome, it can often be confused with hypersensitivity myocarditis and can be the cause of unexplained sudden death. Kounis syndrome has revealed that the same mediators released from the same inflammatory cells are present in acute coronary events of nonallergic etiology. These cells are not only present in the culprit region before plaque erosion or rupture but they release their contents just before an actual coronary event. Therefore, does Kounis syndrome represent a magnificent natural paradigm and nature's own experiment in a final trigger pathway implicated in cases of coronary artery spasm and plaque rupture showing a novel way towards our effort to prevent acute coronary syndromes? Drugs, substances targeting the stem cell factor that is essential for mast cell development, proliferation, survival, adhesion and homing as well as monoclonal antibodies and natural molecules that protect mast cell surface and stabilize mast cell membrane could emerge as novel therapeutic ways capable to prevent acute coronary and acute cerebrovascular events.

Stress-induced cardiomyopathy complicated by multiple organ failure following cephalosporin-induced anaphylaxis

Stress-induced cardiomyopathy, a reversible left ventricular dysfunction, has been reported following anaphylaxis; this clinical circumstance seems to be linked to elevated levels of circulating catecholamines. We present a 36-year-old woman diagnosed as stress-induced cardiomyopathy following ceftriaxone-induced anaphylaxis. After anaphylactic reaction, the patient initially presented with cardiogenic shock, and subsequently developed multiple organ failure. She recovered basically by multiple organ supportive therapies including intra-aortic balloon pump and continuous veno-venous hemofiltration. This case provides a unique opportunity to observe the triggering of stress-induced cardiomyopathy, and also it provides evidence to support the role of catecholamine in the pathogenesis of this disease.

Safety of angiotensin-converting enzyme inhibitors while receiving venom immunotherapy

BACKGROUND

Case reports have raised concern about concurrent use of angiotensin-converting enzyme inhibitors (ACE-Is) in patients receiving venom immunotherapy (VIT). No surveys have been performed on the number of venom allergic patients who take ACE-Is and their outcomes.

OBJECTIVE

To survey the use of ACE-Is and systemic reaction (SR) characteristics in patients receiving VIT.

METHODS

A retrospective medical record review was performed on all patients evaluated for Hymenoptera venom allergy at a single center from 2000 to 2005. Patient records were evaluated for presenting symptoms, specific IgE testing, VIT treatment course, ACE-I use during VIT, and the presence of any SRs to field stings or VIT.

RESULTS

Of 288 patients evaluated from 2000 to 2005 for Hymenoptera venom allergy, 157 were found to have venom specific IgE. Of these 157 patients, 79 (50%) of those with Hymenoptera venom allergy underwent VIT. Seventeen of these 79 patients (21%) were taking an ACE-I during VIT. The mean overlap of a patient taking an ACE-I with the time they were receiving VIT was 30.9 months (range, 3-114 months). Patients taking ACE-Is were older (mean age, 56.2 vs 36.4 years; P < .001) and received VIT for a longer period (mean, 72.3 vs 29.9 months; P < .04). Thirteen of 62 patients not taking an ACE-I (21%) experienced an SR during their VIT. No patients taking an ACE-I experienced an SR to VIT while taking an ACE-I (P = .03).

CONCLUSIONS

This study suggests that there is not an association between ACE-I use and increased frequency of SRs to venom immunotherapy.

Tako-Tsubo-like syndrome during anaphylactic reaction

Tako-Tsubo's syndrome (apical ballooning or broken heart syndrome) is a reversible left ventricular dysfunction due to apical asynergy that occurs typically after sudden emotional stress in a subject without coronary disease. It is characterized by acute onset of chest pain or dyspnoea or both and is associated with electrocardiographic changes such as ST segment elevation and/or T wave inversion. Myocardial biomarkers may be normal or slightly elevated. Anaphylaxis is a severe, life-threatening, generalized hypersensitivity reaction, most often starting with urticaria and/or angioedema, that may involve cardiovascular and respiratory systems. Cardiovascular symptoms, including hypotension, cardiac arrhythmia and chest pain, are presumably linked to cardiac mast cell mediator release. We describe the case of a young woman who experienced a profound reversible cardiomyopathy with typical features of Tako-Tsubo's syndrome during an anaphylactic reaction.

Safety of Angiotensin-converting enzyme inhibitors in patients with insect venom allergies

OBJECTIVE

To review the literature with respect to the safety of angiotensin-converting enzyme (ACE) inhibitors in patients allergic to insect venom and those undergoing venom immunotherapy (VIT).

DATA SOURCES

A MEDLINE search was conducted (1966-March 2006) using the following search terms: bee sting, venom, insect stings, ACE inhibitors, angiotensin II receptor blockers, immunotherapy, and desensitization. The bibliographies of qualifying articles were also searched for relevant references.

DATA SYNTHESIS

Several case reports have described severe allergic reactions, including anaphylaxis, in patients taking ACE inhibitors subsequent to being stung or receiving VIT. Exacerbation of the allergic response by ACE inhibitors is thought to be related to accumulation of bradykinin and inhibition of the formation of angiotensin II. Similar reactions have not been described with angiotensin-receptor blockers, but are theoretically possible.

CONCLUSIONS

ACE inhibitors may exacerbate the response to insect venom, resulting in potentially life-threatening allergic reactions to insect stings or VIT. Although this risk is difficult to quantify based only on data from case reports, it seems prudent that patients with documented allergic reactions to insect venom avoid ACE inhibitor therapy, if possible. If, after careful consideration of the risks and benefits, ACE inhibitor therapy is deemed warranted, education regarding measures to minimize exposure to insect stings and training on self-administration of epinephrine should be provided, as with any person with venom allergy. In patients in whom VIT is appropriate, temporary discontinuation of the ACE inhibitor prior to each venom injection may prevent subsequent adverse reactions.

Prevalence, severity, and natural history of jack jumper ant venom allergy in Tasmania

BACKGROUND

The jack jumper ant (Myrmecia pilosula) is responsible for greater than 90% of Australian ant venom allergy. However, deaths have only been recorded in the island of Tasmania.

OBJECTIVES

We sought to determine the prevalence, clinical features, natural history, and predictors of severity of M pilosula sting allergy in Tasmania.

METHODS

We performed a random telephone survey supported by serum venom-specific IgE analysis, review of emergency department presentations, and follow-up of allergic volunteers.

RESULTS

M pilosula, honeybee (Apis mellifera), and yellow jacket wasp (Vespula germanica) sting allergy prevalences were 2.7%, 1.4%, and 0.6% compared with annual sting exposure rates of 12%, 7%, and 2%, respectively. Similarly, emergency department presentations with anaphylaxis to M pilosula were double those for honeybee. M pilosula allergy prevalence increased with age of 35 years or greater (odds ratio [OR], 2.4) and bee sting allergy (OR, 16.9). Patients 35 years of age or older had a greater risk of hypotensive reactions (OR, 2.9). Mueller reaction grades correlated well with adrenaline use. During follow-up, 79 (70%) of 113 jack jumper stings caused anaphylaxis. Prior worst reaction severity predicted the likelihood and severity of follow-up reactions; only 3 subjects had more severe reactions. Venom-specific IgE levels and other clinical features, including comorbidities, were not predictive of severity.

CONCLUSIONS

Sting allergy prevalence is determined by age and exposure rate. M pilosula sting exposure in Tasmania is excessive compared with that found in mainland Australia, and there is a high systemic reaction risk in allergic people on re-sting. Prior worst reaction severity (Mueller grade) and age predict reaction severity and might be used to guide management.

Ant sting mortality in Australia

We investigated ant sting related fatalities in Australia over the period 1980-1999. Data was obtained from the Australian Bureau of Statistics and state coronial authorities. Six ant sting-related fatalities were identified, five in Tasmania and one in New South Wales. All were males aged between 40 and 80-years-of-age and most (5/6) had prior histories of jumper or bull ant (Myrmecia spp.) venom allergy. However, none of the deceased carried injectable adrenaline and most died within 20 min of a single sting. Significant cardiopulmonary co-morbidities were identified in all cases and, in addition, moderate-severe laryngeal oedema and coronary atherosclerosis was observed in most (4/6) cases at autopsy. Where ascertained, Myrmecia ant venom specific immunoglobulin E antibodies levels were always elevated and fell into two distinct patterns of immunoreactivity. Adult Tasmanian males with a prior history of ant venom allergy and cardiopulmonary co-morbidities are therefore at highest risk of a fatal outcome from ant stings. Deaths may be avoided by the early recognition of anaphylaxis and self-treatment with adrenaline as well as by the development of purified Myrmecia ant venom immunotherapy.

Diffuse alveolar haemorrhage: a rare reaction to insect sting

Insect stings and subsequent reactions are common occurrences, but life-threatening systemic reactions are rare. Herein, we describe the case of a young man who developed diffuse pulmonary haemorrhage following an insect sting. He had experienced urticarial reactions to insect stings previously. Diffuse pulmonary haemorrhage should be recognized as an uncommon manifestation of severe systemic reaction to insect sting.

Tryptase and histamine release due to a sting challenge in bee venom allergic patients treated successfully or unsuccessfully with hyposensitization

BACKGROUND

Hyposensitization with been venom leads to full protection in most, but not all patients with IgE-mediated systemic reactions to bee stings.

OBJECTIVE

To determine the relationship of clinical reactivity to the release of mediators and to changes of antibody concentrations in the peripheral circulation at a bee sting challenge test.

METHODS

Blood was sampled before (1 min) and at 15, 60 and 180 min after a sting challenge from 19 patients on hyposensitization. Of these six still reacted and 13 were protected. Histamine, mast cell tryptase, bee venom-specific IgE and IgG in the serum, and histamine release from peripheral blood leucocytes (PBL) upon exposure to bee venom were determined.

RESULTS

Tryptase above the detection level was found only at 15 (60) min in 4/6 (1/6) patients who reacted. After the sting challenge there was a significant increase of the histamine levels in patients who reacted at 15 min (P < 0.05) and in patients who did react at 60 and 180 min (P < 0.01). The total histamine content of PBL was significantly decreased after 15 and 60 min in patients who reacted (P < 0.01) and in those that did not (P < 0.05). Bee venom-induced histamine release was significantly reduced in patients reacting and those that did not at 15 min (P < 0.05), and was significantly decreased in reactors also at 60 and 180 min (P < 0.05/0.01). Specific IgG antibodies showed a minor decrease (P < 0.05) after the sting challenge in both groups, whereas specific IgE did not change significantly.

CONCLUSION

These results indicate that bee venom anaphylaxis is associated with the release of mediators from both mast cells as well as basophils. Successful hyposensitization does not induce a state of immunological non-reactivity, but rather alters the magnitude and the pattern of mediator release.

Association between the renin angiotensin system and anaphylaxis

Patients with hymenoptera venom anaphylaxis before immunotherapy (n = 50) showed significantly lower renin, angiotensinogen, angiotensin I and angiotensin II as compared to healthy non-allergic controls (n = 25) (p < 0.05). A significant inverse correlation between the severity of clinical symptoms and the plasma levels of renin, angiotensinogen, angiotensin I and angiotensin II was found: the lower the levels the more severe the clinical symptoms. Hymenoptera venom allergic patients with repeated anaphylactic reactions during hyposensitizatin did not tolerate the sting of a living insect (n = 6). Sting provocation with a living insect induced clinical symptoms of anaphylaxis in all of the 6 patients. Renin, angiotensinogen, angiotensin I and II remained significantly lower in these patients as compared to healthy non-allergic controls. Likewise, no stimulation of the renin angiotensin system occurred during the anaphylactic reaction. The values of angiotensin II were similar or lower than the values before the anaphylactic reaction. In contrast, patients with successful immunotherapy (n = 27) who tolerated the sting of a living insect, renin, angiotensin I and II were significantly higher than in patients without immunotherapy. After immunotherapy, the values for renin, ANG I and ANG II were similar to the values found in healthy non-allergic controls. Patients with a history of hymenoptera venom anaphylaxis (n = 22) showed significantly lower ANG II concentrations in their leukocytes as compared to healthy non-allergic controls (n = 24). Successful immunotherapy induced a significant 9-fold increase in ANG II as compared to patients without immunotherapy. These findings suggest a possible role of the renin angiotensin system in hymenoptera venom anaphylaxis.