Hymenoptera stings: Difference between revisions
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*Non barbed stinger - can sting multiple times and the sting does not cause the wasps' death | *Non barbed stinger - can sting multiple times and the sting does not cause the wasps' death | ||
*Histamine, phospholipase, antigen 5, and bradykinin similar to bees<ref name="King"></ref> | *Histamine, phospholipase, antigen 5, and bradykinin similar to bees<ref name="King"></ref> | ||
* | *Redness and irritation last 1-3 days | ||
===Fire Ants (Formicidae)=== | ===Fire Ants (Formicidae)=== | ||
[[File:Fire ants 01.jpg|thumb|Fire ants]] | [[File:Fire ants 01.jpg|thumb|Fire ants]] | ||
*''Solenopsis invicta'' (red fire ant) and ''Solenopsis richteri'' (black fire ant) | |||
*Alkaloid venom | *Alkaloid venom | ||
*Intense burning papules that may turn to pustules in 24hrs | *Intense burning papules that may turn to pustules in 24hrs | ||
*Localized necrosis has also been reported<ref>Fernández-Meléndez S. et al. Anaphylaxis caused by imported red fire ant stings in Málaga, Spain. J Investig Allergol Immunol. 2007;17(1):48-49</ref> | *Localized necrosis has also been reported<ref>Fernández-Meléndez S. et al. [[Anaphylaxis]] caused by imported red fire ant stings in Málaga, Spain. J Investig Allergol Immunol. 2007;17(1):48-49</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
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[[File:Bee sting 5.jpg|thumb|Local reaction: 1 day after bee sting]] | [[File:Bee sting 5.jpg|thumb|Local reaction: 1 day after bee sting]] | ||
[[File:FireAntBite.jpg|thumb|Local reaction: Fire ant bite]] | [[File:FireAntBite.jpg|thumb|Local reaction: Fire ant bite]] | ||
*Urticarial lesion contiguous with sting site | *[[urticaria|Urticarial]] lesion contiguous with sting site | ||
*Severe local reaction may involve one or more neighboring joints | |||
*Local reaction occurring in mouth or throat can produce airway obstruction | *Local reaction occurring in mouth or throat can produce airway obstruction | ||
*Local reaction occurring around eye can result in cataract, iris atrophy, globe | *Local reaction occurring around eye can result in cataract, iris atrophy, [[globe rupture|globe perforation]] | ||
===Toxic Reaction=== | ===Toxic Reaction=== | ||
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*May be delayed 8-24hrs | *May be delayed 8-24hrs | ||
*Venom mediated, not IgE | *Venom mediated, not IgE | ||
*Resembles anaphylaxis but greater frequency of nausea/vomiting and diarrhea | *Resembles [[anaphylaxis]] but greater frequency of [[nausea/vomiting]] and [[diarrhea]] | ||
**Other symptoms: light-headedness, syncope, headache, fever, drowsiness, muscle spasms | **Other symptoms: [[dizziness|light-headedness]], [[syncope]], [[headache]], [[fever]], [[fatigue|drowsiness]], muscle spasms | ||
*Massive stings can result in renal or hepatic failure, DIC, rhabdo | *Massive stings can result in [[renal failure|renal]] or [[hepatic failure]], [[DIC]], [[rhabdo]] | ||
*Systemic toxicity more likely if > 50 stings | *Systemic toxicity more likely if > 50 stings | ||
*Median lethal dose of honeybee venom ~19 stings/kg or 500-1400 stings per human | *Median lethal dose of honeybee venom ~19 stings/kg or 500-1400 stings per human | ||
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===Delayed Reaction=== | ===Delayed Reaction=== | ||
*May occur 5-14d after a sting | *May occur 5-14d after a sting | ||
*Serum | *[[Serum sickness]] features (fever, malaise, urticaria, lymphadenopathy, polyarthritis) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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*Stinger Removal | *Stinger Removal | ||
**Immediate removal is the most important principle; the method of removal is irrelevant | **Immediate removal is the most important principle; the method of removal is irrelevant | ||
*Local wound care and tetanus prophylaxis | *Local wound care and [[tetanus prophylaxis]] | ||
*Oral [[Antihistamines]] provide symptom relief for pruritus | *Oral [[Antihistamines]] provide symptom relief for [[pruritus]] | ||
===Local Reaction=== | ===Local Reaction=== | ||
*Ice packs diminish swelling and delays absorption of venom | *Ice packs diminish swelling and delays absorption of venom | ||
*NSAIDs and antihistamines for comfort | *[[NSAIDs]] and [[antihistamines]] for comfort | ||
*Infection is uncommon, but may present as ongoing swelling or cellulitis | *Infection is uncommon, but may present as ongoing swelling or [[cellulitis]] | ||
===Systemic reaction=== | ===Systemic reaction=== | ||
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*Normally outpatient, unless [[anaphylaxis]] or systemic toxicity | *Normally outpatient, unless [[anaphylaxis]] or systemic toxicity | ||
**EpiPen should be prescribed on discharge if significant reaction | **EpiPen should be prescribed on discharge if significant reaction | ||
*Admission/observation for victims with >100 stings, substantial comorbidities, those at extremes of age | |||
==See Also== | ==See Also== | ||
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-the size of the bee’s stinger | -the size of the bee’s stinger | ||
+the nature of the most severe previous reaction experienced by the patient | +the nature of the most severe previous reaction experienced by the patient | ||
||Freeman TM. Hypersensitivity to Hymenoptera stings. N Engl J Med 2004; 351: 1978-1984. The risk of anaphylaxis with any event is dependent on the nature of the most severe previous reaction experienced by a patient Local reactions are best treated symptomatically with nonsteroidal antiinflammatory agents, antihistamines, and cold compresses. The definitive therapy for anaphylaxis is epinephrine by injection (0.01mg per kilogram of body weight; maximum, 0.3 and 0.5mg per dose, for children and adults, respectively), and this should be administered to any patient who has more than a cutaneous reaction. Antihistamines are often added to treat cutaneous signs and symptoms. Supplemental oxygen, beta-agonists for bronchospasm, and intravenous fluids for hypotension are sometimes indicated. Occasionally, for a reaction that does not respond to the initial dose of epinephrine, steroids (oral or intravenous) are added, although definitive support for their addition is lacking. Epinephrine auto-injectors should be prescribed for any patient who has had an anaphylactic reaction to a hymenoptera sting. The instructions for use are printed on the side of each injector, but these should be reviewed with the patient when prescribing the medication. Patients should be educated to use epinephrine if signs or symptoms beyond a cutaneous reaction develop after a hymenoptera sting, and always to seek additional medical care after using an injector. Patients should also be advised to wear a medical alert bracelet. Referral to an allergist is warranted, and skin testing should be performed for sensitivity to honeybees, wasps, white-faced hornets, yellow hornets, and yellow jackets. Venom immunotherapy should be administered for all venoms for which testing results are positive. The protective benefit is expected from the immunotherapy by the time maintenance dose is reached, usually by three to six months with standard protocols. | ||Freeman TM. Hypersensitivity to Hymenoptera stings. N Engl J Med 2004; 351: 1978-1984. The risk of anaphylaxis with any event is dependent on the nature of the most severe previous reaction experienced by a patient Local reactions are best treated symptomatically with nonsteroidal antiinflammatory agents, antihistamines, and cold compresses. The definitive therapy for anaphylaxis is epinephrine by injection (0.01mg per kilogram of body weight; maximum, 0.3 and 0.5mg per dose, for children and adults, respectively), and this should be administered to any patient who has more than a cutaneous reaction. Antihistamines are often added to treat cutaneous signs and symptoms. Supplemental oxygen, beta-agonists for bronchospasm, and intravenous fluids for hypotension are sometimes indicated. Occasionally, for a reaction that does not respond to the initial dose of epinephrine, steroids (oral or intravenous) are added, although definitive support for their addition is lacking. [[Epinephrine]]auto-injectors should be prescribed for any patient who has had an anaphylactic reaction to a hymenoptera sting. The instructions for use are printed on the side of each injector, but these should be reviewed with the patient when prescribing the medication. Patients should be educated to use epinephrine if signs or symptoms beyond a cutaneous reaction develop after a hymenoptera sting, and always to seek additional medical care after using an injector. Patients should also be advised to wear a medical alert bracelet. Referral to an allergist is warranted, and skin testing should be performed for sensitivity to honeybees, wasps, white-faced hornets, yellow hornets, and yellow jackets. Venom immunotherapy should be administered for all venoms for which testing results are positive. The protective benefit is expected from the immunotherapy by the time maintenance dose is reached, usually by three to six months with standard protocols. | ||
-the amount of cutaneous erythema | -the amount of cutaneous erythema | ||
-whether the patient is on oral steroid treatment | -whether the patient is on oral steroid treatment | ||
Latest revision as of 23:33, 8 February 2021
Background
- All Hymenoptera share similar components in their venonm and patients can have allergies across the subgroups[1]
- Most reactions are local but anaphylaxis and serum sickness are possible
Bees (Apids)
- Include Bumblebees and Honeybees
- Barbed Stingers - remain in victims and the process of stinging kills the bee
- Killer bees (hybridized African Bees) have small individual toxin potency but attack in large numbers with increased aggression[2]
- Main allergen is phospholipase A2, hyaluronidase and melittin[1]
- redness and irritation last 1-3 days
Wasps (Vespids)
- Include Yellow Jackets, Hornets, and Wasps
- Non barbed stinger - can sting multiple times and the sting does not cause the wasps' death
- Histamine, phospholipase, antigen 5, and bradykinin similar to bees[1]
- Redness and irritation last 1-3 days
Fire Ants (Formicidae)
- Solenopsis invicta (red fire ant) and Solenopsis richteri (black fire ant)
- Alkaloid venom
- Intense burning papules that may turn to pustules in 24hrs
- Localized necrosis has also been reported[3]
Clinical Features
Local Reaction
- Urticarial lesion contiguous with sting site
- Severe local reaction may involve one or more neighboring joints
- Local reaction occurring in mouth or throat can produce airway obstruction
- Local reaction occurring around eye can result in cataract, iris atrophy, globe perforation
Toxic Reaction
- Occurs after multiple stings
- May be delayed 8-24hrs
- Venom mediated, not IgE
- Resembles anaphylaxis but greater frequency of nausea/vomiting and diarrhea
- Other symptoms: light-headedness, syncope, headache, fever, drowsiness, muscle spasms
- Massive stings can result in renal or hepatic failure, DIC, rhabdo
- Systemic toxicity more likely if > 50 stings
- Median lethal dose of honeybee venom ~19 stings/kg or 500-1400 stings per human
Anaphylactic reaction
- Majority occur within first 15min; nearly all within 6hr
- No correlation with number of stings
- IgE mediated, rather than direct response to the venom.
- Shorter the interval between sting and onset of symptoms the more severe the reaction
Delayed Reaction
- May occur 5-14d after a sting
- Serum sickness features (fever, malaise, urticaria, lymphadenopathy, polyarthritis)
Differential Diagnosis
Envenomations, bites and stings
- Hymenoptera stings (bees, wasps, ants)
- Mammalian bites
- Closed fist infection (Fight bite)
- Dog bite
- Marine toxins and envenomations
- Toxins (ciguatera, neurotoxic shellfish poisoning, paralytic shellfish poisoning, scombroid, tetrodotoxin
- Stingers (stingray injury)
- Venomous fish (catfish, zebrafish, scorpion fish, stonefish, cone shells, lionfish, sea urchins)
- Nematocysts (coral reef, fire coral, box jellyfish, sea wasp, portuguese man-of-war, sea anemones)
- Phylum porifera (sponges)
- Bites (alligator/crocodile, octopus, shark)
- Scorpion envenomation
- Reptile envenomation
- Spider bites
Evaluation
- Usually clinical
Management
- Stinger Removal
- Immediate removal is the most important principle; the method of removal is irrelevant
- Local wound care and tetanus prophylaxis
- Oral Antihistamines provide symptom relief for pruritus
Local Reaction
- Ice packs diminish swelling and delays absorption of venom
- NSAIDs and antihistamines for comfort
- Infection is uncommon, but may present as ongoing swelling or cellulitis
Systemic reaction
- Treat similar to anaphylaxis
Disposition
- Normally outpatient, unless anaphylaxis or systemic toxicity
- EpiPen should be prescribed on discharge if significant reaction
- Admission/observation for victims with >100 stings, substantial comorbidities, those at extremes of age
See Also
References
- ↑ 1.0 1.1 1.2 King TP et al. Structure and biology of stinging insect venom allergens. Int Arch Allergy Immunol. 2000;123(2):99-106
- ↑ Díaz-Sánchez C. et al. Suvival after massive (>2000) Africanized Honey bee stings. Arch Intern Med. 1998;158(8):925-927
- ↑ Fernández-Meléndez S. et al. Anaphylaxis caused by imported red fire ant stings in Málaga, Spain. J Investig Allergol Immunol. 2007;17(1):48-49
Review Questions