Was the death of a pharaoh the first report of an insect sting reaction?
In 1989,an article in Hospital Practice by Ovary stated that the death of Pharaoh Menes after a wasp sting in 2600 BC was the first reported account of an anaphylactic reaction to insect stings. According toKrombach, this was based on hieroglyphs found on his sarcophagus and tomb. Dynasties that came after Menes believed him to be the first Pharaoh and he is credited with many things, including the introduction of papyrus and writing. ButKrombach and his fellow authors argue that he was likely a mythical figure who may not have even lived. Oh well -- so much for exotic origins. No matter when the first reaction was, it is likely that insect sting allergy started a very long time ago.Statistics
A review article in the June 2015 Journal of Allergy and Clinical Immunology In Practice spoke about the state of the art in treating stinging insect allergy. Reactions to stinging insects account for 10% of all cases of anaphylaxis presenting to emergency rooms and there are about 40 deaths per year in the US due to these reactions. The estimate is that 0.4% to 0.8% of children and 2% to 3.5% of the general adult population experience systemic reactions to insect stings at some point in their lives.
The Players
The Hymenoptera are the most studied stinging insects, with purified, commercial venoms for testing and treatment in the United States. Hymenoptera include the Apidae (honeybee) and Vespidae (aerial yellow jacket or New World hornets) which include Vespinae (yellow jackets and aerial yellow jackets) and Polistinae (wasps). There are also a number of types of stinging ants. The most common in the US and best studied is the Imported Fire Ant (IFA), Solenopsis invicta. Since inadvertent importation through Mobile, Alabama during 1930-1940, this fire ant has spread throughout the Southeast of the US as far north as Maryland and even into the arid southwest.
What are the different kinds of reactions to insect stings?
There are five types of reactions to insect stings, according to Koterba and Greenberger. These include:
· A normal reaction with less than 2 inches of redness and swelling right around the sting and which subsides in less than a day. For this, cold compresses and analgesics (pain medication) are sufficient treatment.
· A large local reaction with extensive redness and swelling, generally more than 5 inches in size and lasting 1-10 days. These reactions can involve large areas – for example, a whole arm. Analgesics, ice and sometimes prednisone is the usual treatment.
· Anaphylaxis includes swelling that skips a joint area or occurs at areas of the body distant from the site of the sting. Hives can also accompany this reaction. The patient may have life threatening symptoms such as swelling of the larynx (which may cut off breathing) or cardiac involvement. Treatment includes urgent use of epinephrine (generally administered by an automatic injector such as EpiPen or Auvi Q) and calling EMS for a trip to the emergency room. Patients who have these reactions should be skin tested and considered for desensitization to the venom or venoms to which they are shown to be allergic. If the reaction is only hives in a child less than 16 years old, life threatening reactions usually do not develop on re-sting so desensitization may not be necessary in this case.
· Rare reactions: These include serum sickness with hives, fever, malaise and joint pain that occurs 7 days after the sting. Some of these patients may experience anaphylaxis on subsequent stings, so desensitization is suggested.
· Toxic reactions: These happen with multiple simultaneous stings such as may occur in an attack by Africanized honey bees. Hypotension, cardiovascular collapse and death may occur.
How can you tell which kind of insect stung you?
There are five types of stinging insects to which allergists test – Yellow Jacket, Honeybee, White Faced Hornet, Yellow-Faced Hornet, and Wasp. According to the American Academy of Asthma, Allergy and Immunology, here are some of the characteristics of these insects:
• Yellow jackets are black with yellow markings, found in various climates. Their nests are usually located underground, but sometimes found in the walls of buildings, cracks in masonry or in woodpiles.
• Honeybees have round, fuzzy bodies with dark brown and yellow markings. They can be found in honeycombs in trees, old tires or other partially protected sites. Honeybees are the only Hymenoptera insects that leave their stinger in the skin after a sting.
• Paper wasps are slender with black, brown, red and yellow markings. They live in a circular comb under eaves, behind shutters or in shrubs and woodpiles.
• Hornets are black or brown with white, orange or yellow markings. Their nests are gray or brown and are usually found in trees.
Why is it important for you to be able to identify the type of insect that stung you when you have had a reaction? It is important because your allergist at Allergy Partners uses this information in conjunction with skin tests to determine which type of venom to use for desensitization.
It is very important for the doctor to get a good history, including what type of insect was involved and the details of the reaction. Identification of the type of insect that caused the reaction through history and skin testing as well as the nature of the reaction can be lifesaving.
Is there anything that can be done?
Skin tests to stinging insects can show false negatives in up to 20% of cases, and so blood tests may then be helpful. In some cases, it is important to get a baseline tryptase level. If elevated, it may make the sting reaction more severe. If you are skin test positive to one or more venoms after you have had a systemic or anaphylactic reaction to an insect sting, your allergist can prescribe desensitization injections which will reduce the likelihood of a reaction to 3% from 60%. The exception is in children under 16 who have only had skin reactions (usually hives) as these patients generally do not progress to more severe reactions with subsequent stings. It takes about 15 injections, barring local or systemic reactions to the shots, to get to a “maintenance” dose. Once maintenance is reached, injections can be given once per month during the first year and every 6-8 weeks during the subsequent years. Venom immunotherapy is typically given for 5 years, but may be continued for a longer duration in certain instances.
Your Allergy Partners physician will work with you to determine the best course for you.
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