Bee and Wasp Stings
                            ===================
þ Beesting Epidemiology:
 - about 40/year.
 - Anaphylaxis occurs in less than 1% of those stung.

þ Differences in Bees and Stings
 - Though bees (Apidae, as opposed to Vespid wasps) leave their stingers in,
   they are seldom seen, because they are quickly brushed off.

þ Beesting anaphylaxis/anaphylactiod reactions
 - Only half of those with systemic reactions and a positive venom skin test
   will have repeat anaphylaxis following re-stings (common experience).
 - Venom-specific IgE titers don't correlate with severity of reactions; some
   with anaphylaxis have no detectable specific IgE.
   A retrospective study of 65 first-sting anaphylaxis patients
   (about 10% of all sting anaphylaxis is first-sting from this study) found
   1/3 were atopic.  23% had negative skin tests and negative RAST.  They
   suggest that some reactions may be "anaphylactoid" directly due to
   toxins in the sting rather than from true anaphylaxis.  Some may have
   vagal hypotension after a sting, and this is erroneously diagnosed as
   anaphylaxis.
   [Resisman R, Osur S. Allergic reactions following first insect sting
   exposure. Ann Allergy 1987;59:429.]
þ Do you need antibiotics for beesting reactions that are hot and red?
 - no real evidence but common experience against it.
 - We presented an abstract at SAEM that showed one clear case of cellulitis,
   temp of 102, pus but no real other cases of around 250, hasn't been
   published, first author has never written it up.
   --Robert McNamara, MD, FAAEM
     Program Director, Emergency Medicine
     Medical College of Pennsylvania and Hahnemann University

þ Venom Immunotherapy
 - These are the classic articles in the pediatric literature.  They are a
   retrospective study of 246 patients.  Subsequent reactions were never as
   serious as the original sting, so they conclude that children with
   non-life-threatening systemic reactions do not require immunotherapy.
   [Schubert K, et al.  Epidemiolgic study of insect allergy in children,
   Part I. J Pediatrics 1982;100;546. Schubert K, et al.  Epidemiolgic
   study of insect allergy in children, Part II.  J Pediatrics 1983;102:361.]
 - Subsequent stings not as bad also in another study
   [Muriella et al. J Allergy Clin Immunol 1984;74:494.]
 - In one study of 158 patients, 20% were atopic.  Head/neck stings not more
   serious in this study.  75% had cardiovascular symptoms, and 20% had
   syncope. Two had non-fatal cardiac arrest, and one had a seizure. These
   patients had a significant risk (39%) of re-sting anaphylaxis (63% if LOC
   occurred) if not given immunotherapy.
   [Lantner R, Reisman R.  Clinical and immunologic features and supsequent
   course of patients with severe insect sting anaphylaxis.  J Allergy Clin
   Immunol 1989;84:900.]
 - Immunotherapy drops IgE massively, but not IgG levels, over 3-5 years.
 - Different approaches:
   "Traditional" approach to insect allergy:
  + if history of systemic reaction,
  + check skin test or RAST;
  + if +, then give immunotherapy.
   "Modern" approach:
  + treat mild reactions only in adults, and only if patient or MD prefers;
  + treat moderate reactions in kids or adults only if patient or MD prefers;
  + treat severe reactions in both kids and adults
  --David Graft, MD, at 1998 PaACEP Annual Conference
 - Studies of Immunotherapy:
  + Johns Hopkins Children's Insect Sting Study found 18.6% systemic reactions
    (1% of them as serious as original) in untreated patients and 2.8%
    systemic reactions (none as serious as the original) in the treated group.
    [Valentino MD, Schuberth KC, Kager-Sabotka A, Graft EF, et al. The value
    of immunotherapy with venom in children with allergy to insect stings N
    Engl J Med 1990;323:1601-03]