Venom immunotherapy: when is it reasonable to stop.
Explore the source record for details and available documents.
Desensitization, Immunologic↗
Biomedical subjects
R E Reisman
Publications and source records attributed to R E Reisman.
A double-blind study of the effectiveness of a high-efficiency particulate air (HEPA) filter in the treatment of patients with perennial allergic rhinitis and asthma.
This study was designed to assess the effectiveness of a high-efficiency particulate air (HEPA) filter in alleviating allergic respiratory symptoms. Thirty-two patients were studied who had symptomatic perennial rhinitis and/or asthma during the fall and winter months and had a positive skin test with house dust or house dust--mite extract. An ENVIRACAIRE room air cleaner was placed in the bedroom for 8 weeks. In a random manner, the active filter was used for 4 weeks and a blank filter for 4 weeks. There was an average 70% reduction in the particulate matter greater than or equal to 0.3 micron with the HEPA filter. In a double-blind design, results were assessed by analysis of the patients' symptom/medication scores and subjective evaluation. For the total study, there was no difference in the total symptom/medication scores or individual symptom scores during the placebo and active-filter periods. Analysis of the last 2 weeks of each filter period in which respiratory infection was absent demonstrated definite differences in total and individual symptoms, suggesting active-filter benefit. Patients' subjective responses also suggested benefit from the filter. The overall impression is that the HEPA filter can reduce allergic respiratory symptoms.
Adolescent↗
Phospholipase A2 in venom extracts from honey bees (Apis mellifera L.) of different ages.
We measured phospholipase A2 activity in the venom of worker honey bees (Apis mellifera L.) of known ages using chemical (titrimetric) and radioallergosorbent methods. The two techniques give similar results. Low levels of phospholipase A2 are present in the venom system at the time of eclosion. Phospholipase A2 activity in the venom increases steadily through the 10 days after eclosion. Maximal phospholipase A2 levels (about 40 micrograms phospholipase A2/venom sac) are maintained through the rest of the life of a worker bee in summer.
Aging↗
Clinical and immunologic features and subsequent course of patients with severe insect-sting anaphylaxis.
One hundred fifty-eight patients were evaluated because of symptoms of potentially fatal venom anaphylaxis, as defined by hypotension, including loss of consciousness (LOC), throat/laryngeal edema, or marked respiratory distress. The demographic characteristics were 118 male and 40 female patients; age range, 3 to 80 years; mean, 29.7 years; 33 patients less than 10 years; and incidence of atopy, 20%. One hundred twenty-seven patients had had prior stings; 27 had prior systemic reactions (SR), including one with LOC. Almost all patients had venom-specific IgE; RAST titers covered a wide range. As compared to the total group, the subset of 45 patients with LOC were older, had an increased incidence of cardiac disease and beta-blocker use, stings in the head area, and re-sting reactions in patients who did not receive venom immunotherapy (VIT). One hundred six re-stings occurred in 37 patients receiving VIT with no SR. There were 38 re-stings in 18 patients who refused VIT, with 14 SRs in 11 patients. These studies suggest no distinguishing characteristics, including age, that would identify patients susceptible to severe venom anaphylaxis and confirm the prophylactic effectiveness of VIT.
Adolescent↗
Late-onset allergic reactions, including serum sickness, after insect stings.
Allergic reactions after insect stings may have a delayed onset, differing from the usual immediate anaphylactic pattern. Ten patients, aged 6 to 78 years, had allergic reactions 1 to 2 weeks after an insect sting. Six patients had had multiple stings preceding the reaction. In two instances, immediate anaphylaxis also occurred. Four of the 10 patients had serum sickness-type reactions; two other patients had more severe anaphylactic symptoms, including throat edema. All patients in this group had venom-specific IgE; four of the 10 patients had serum venom-specific IgG. Eight patients subsequently received venom immunotherapy (VIT). There have been no reactions from seven re-stings. Five patients had generalized hives starting 6 to 24 hours after an insect sting. All patients in this group had venom-specific IgE; three patients have received VIT. Two other patients developed hives, one with throat edema 3 days after an insect sting. Both patients had high titers of serum venom-specific IgE; neither patient has received VIT, one patient because of extreme sensitivity. These observations suggest that after an insect sting, patients may develop delayed-onset allergic symptoms that range from typical anaphylaxis to serum sickness and are mediated by venom-specific IgE. VIT is recommended for patients with these reactions.
Adult↗
Further observations of stopping venom immunotherapy: comparison of patients stopped because of a fall in serum venom-specific IgE to insignificant levels with patients stopped prematurely by self-choice.
This study extends our experience applying the criterion of a fall in serum venom-specific IgE (RAST) to insignificant levels as an indication to stop venom immunotherapy (VIT) and compares the follow-up results with the results of re-stings in patients who stopped VIT "prematurely" by self-choice. All patients in both groups had a history of venom anaphylaxis, most with cardiovascular and/or respiratory symptoms and initial elevated serum venom-specific IgE; all patients received VIT. The groups were closely matched for age, sex, nature of initial sting reaction, and insect identification. In the group with low-level RAST titers, the duration of VIT was 6 months to 5 years (mean 2 1/2 years). Re-stings occurred from 1 month to 7 years (mean 2.2 years) after cessation of therapy. There were 75 re-stings in 41 patients with four systemic reactions (10% per patient and 5% per sting). All four reacting patients had tolerated several stings during cessation of VIT before the re-sting systemic reaction; two patients had subsequent stings with no reaction. In the group of patients who stopped VIT for other reasons, the duration of VIT was 5 months to 4 years (mean 1.8 years). Re-stings occurred from 4 months to 6 years (mean 2.1 years) after stopping therapy. There were 74 re-stings in 38 patients with seven systemic reactions in four patients (9.5% per patient and 10.5% per sting). Two of the reacting patients had tolerated stings before the re-sting reaction.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Analysis of differing patterns of cross-reactivity of honeybee and yellow jacket venom-specific IgE: use of purified venom fractions.
Prior studies of sera from insect sting-allergic patients have analyzed the relationship of coexisting honeybee venom- and yellow jacket venom-specific IgE. Radioallergosorbent (RAST)-inhibition tests with these venoms revealed four different patterns of activity. In this present study, purified fractions prepared from these venoms were used to analyze these varying patterns. The hyaluronidases of yellow jacket venom and honeybee venom showed extensive cross-reaction. The phospholipases from these venoms showed minimal cross-reactivity; antigen 5 was restricted to yellow jacket venom. There was a high molecular weight component in yellow jacket venom with immunologic properties similar to honeybee venom acid phosphatase. Sera from individual patients showed quantitative and qualitative differences in the reactions to the major components of both venoms. The differences in the RAST-inhibition patterns in patients with elevated levels of both honeybee venom- and yellow jacket venom-specific IgE are accounted for by these differences as well as by differences in the cross-reactivity between the individual components.
Animals↗
Relationship of serum venom-specific IgE titers to clinical aspects of stinging insect allergy.
Fifty patients were randomly selected who had markedly elevated titers of serum venom-specific IgE (range 100-340 IU, mean 144 IU), and compared with 50 patients with low titers (range 0-50 IU, mean 25 IU). At the time serum was obtained, none of the patients had received venom immunotherapy (VIT). Analysis of the demographic data showed more children in the high-RAST group, and comparable matching of the groups for sex, presence of atopy, and culprit insect identification. The nature of the reaction preceding evaluation was similar in both groups. In the high-RAST group, there were 12 local, 15 mild systemic, and 23 severe systemic reactions. In the low-RAST group, there were 8 local, 15 mild systemic, and 27 severe systemic reactions. Other prior local reactions had occurred in 4 high-RAST and 4 low-RAST patients, and other prior systemic reactions had occurred in 3 high-RAST and 8 low-RAST patients. The incidence of systemic and local reactions following VIT was low in both groups. All but 1 patient in each group reached maintenance venom doses. Following initiation of VIT, 10 of 28 patients in the high-RAST group and 5 of 29 patients in the low-RAST group had a further rise in antibody titers. Patients in both groups showed a decrease in titers over a period of time, with or without VIT. Serum venom-specific IgG was greater in the high-RAST group (mean 9.4 U) than in the low-RAST group (mean 3.8 U). The absolute titers of serum venom-specific IgE appear unrelated to any specific feature of stinging insect sensitivity.
Adolescent↗
Prolonged interval maintenance venom immunotherapy.
Current guidelines recommend indefinite administration of venom immunotherapy at 4-week intervals. To simplify this therapy, we examined the clinical and immunologic response after extending the interval between maintenance venom injections to 6, 8, and 12 weeks. Twenty-six patients who had had sting anaphylaxis and positive skin tests received maintenance bee or yellow jacket venom immunotherapy at greater or equal to 6-week intervals. This extended interval was started after a prior average 4-week maintenance interval of 2.3 years. Injections were given at 6-week intervals to all 26 patients and extended to 8-week intervals in 10, and 12-week intervals in 3 patients. Following venom injections, there were 14 mild local reactions and no systemic reactions. No adjustment in dosing was necessary. While on prolonged interval maintenance venom immunotherapy, there were 17 re-stings in 12 patients with no systemic reactions. During prolonged interval maintenance venom immunotherapy, either the serum venom-specific IgG increased or the already elevated titers remained the same in 18 patients and decreased in 2. In the others, preexisting titers were low and unchanged. Serum venom-specific IgE tended to slowly decrease. These clinical and immunologic data suggest that a 4-week maintenance interval may be safely extended.
Adolescent↗
Late onset reactions following venom immunotherapy and venom skin tests.
This report describes patients who had late onset reactions following venom immunotherapy and venom skin tests. Six adult patients had symptoms of fatigue, malaise, fever, headache, and joint ache, starting four to six hours after venom immunotherapy and lasting up to four days. Two of the patients had prolonged reactions at or adjacent to the skin test sites. All of these patients had a history of venom anaphylaxis; four had severe cardiovascular symptoms. All received yellow jacket venom immunotherapy and four honeybee venom immunotherapy. In four patients, the reactions occurred following small venom doses, 0.1 to 2 micrograms. Two patients reacted after maintenance doses of 50 micrograms. There was no relationship to the serum IgE or IgG antibody titers. All but one patient had serum venom-specific IgE but the titers covered a wide range. Serum venom-specific IgG was present in four patients. There was no response in lymphocyte culture to bee venom stimulation in two patients. Two of these patients stopped venom immunotherapy; one had reached the maintenance dose. In three patients, prophylactic parenteral steroids have ameliorated the reactions. After a temporary dose reduction, the sixth patient is now asymptomatic. A seventh patient developed asthma, 12 hours following a maintenance dose of 50 micrograms of yellow jacket venom. Concomitant steroid administration has effectively prevented the reaction. Another patient, a 6-year-old boy, developed fever, edema of the face and lips, erythema of the leg, and a large, tender right inguinal node eight hours following venom skin tests.(ABSTRACT TRUNCATED AT 250 WORDS)
Humans↗
Studies of the natural history of stinging-insect allergy: long-term follow-up of patients without immunotherapy.
This study reports the clinical and immunologic responses of 29 patients who were observed during a prolonged period after insect-sting anaphylaxis without venom immunotherapy. At the time of their initial evaluation, all patients had venom-specific IgE, detected by skin test or RAST. Their mean age was 21 years; 16 patients were 16 years of age or less. There were 18 male and 11 female patients. Eleven patients had urticaria and angioedema as their only symptoms of anaphylaxis, and 18 patients had respiratory and/or cardiovascular symptoms. Reassessment was done 5 or more years after the initial evaluation. The average time at reevaluation was 10.1 years after the initial sting reaction. There had been 25 re-stings in 17 patients, with three systemic reactions occurring in two patients, an overall reaction rate of 12%. The time interval between the initial sting reaction and the follow-up sting was 2 to 14 years, mean 7.3 years. In patients with initial urticaria/angioedema symptoms only, there were 11 re-stings with no reactions. In patients with initial cardiovascular/respiratory symptoms, there were 14 re-stings with three reactions. At the time of follow-up evaluation, venom-specific IgE had generally decreased. In six of 25 patients, venom skin tests became negative, and in eight of 24 patients, the RAST became negative. These observations suggest that in many patients, stinging insect allergy is a self-limited process, with loss of clinical sensitivity and immunologic reactivity.
Adolescent↗
Further studies of patients with both honeybee- and yellow-jacket-venom-specific IgE.
Twenty-five sera from patients with high titers of both honeybee- and yellow-jacket-venom-specific IgE were analyzed in RAST inhibition experiments, using each venom as the coupling and inhibiting antigen. Eight sera had unique antibody activity with no cross-reactivity between yellow-jacket- and honeybee-venom-specific IgE. In 5 sera, the IgE antibody activity was directed at a major allergen in yellow jacket venom cross-reacting with a minor allergen in honeybee venom. Honeybee venom inhibited only the honeybee venom RAST; yellow jacket venom inhibited both the honeybee and the yellow jacket venom RAST. Five sera showed the opposite pattern with IgE antibody directed at a major allergen in honeybee venom cross-reacting with a minor allergen in yellow jacket venom. The fourth newly observed pattern was that of extensive IgE antibody cross-reaction found with 7 sera. Both honeybee venom and yellow jacket venom inhibited both the honeybee and yellow jacket venom RASTs. There were no clinical features such as age, sex, atopy or type of anaphylactic symptoms which could distinguish patients in each group. All but one patient had a history of multiple sting exposures. These data suggest multiple allergens in honeybee and yellow jacket venom with differing patterns of cross-reactivity and have important implications for proper venom immunotherapy.
Adolescent↗
Allergic reactions following first insect sting exposure.
Over a 10-year period, 750 patients were evaluated because of anaphylaxis following insect stings. Sixty-five patients were identified who had reactions after their first sting exposure. Their clinical features and symptoms of anaphylaxis were the same as the much larger group of patients who had allergic reactions following prior exposure to insect stings. When evaluated following the sting reaction, the majority of these patients had venom-specific IgE detected by skin test or in the serum by the RAST. Fifty-three re-stings occurred in 31 patients. In untreated or whole body extract-treated patients, there were 43 re-stings resulting in 13 reactions. There were no reactions following 10 re-stings in venom-treated patients. In a subgroup of 15 patients with undetectable venom-specific IgE, there were 16 re-stings in eight patients, leading to three systemic reactions. The occurrence of allergic reactions following first sting exposure adds further support to the thesis that some sting reactions are non-IgE-mediated.
Adolescent↗
Lack of correlation between titers of serum allergen-specific IgE and symptoms in untreated patients with seasonal allergic rhinitis.
In five ragweed seasons and three grass pollen seasons, preseason and postseason ragweed-specific serum IgE and nasal secretory-specific IgE and IgA have been measured in untreated patients with seasonal allergic rhinitis. There was no consistent correlation between severity of rhinitis, as measured by symptom/medication scores during the season, and either absolute or changes in antibody titers. These findings suggest that antibody levels are only one of the factors that determine symptom severity.
Adolescent↗
Evaluation of decline in serum venom-specific IgE as a criterion for stopping venom immunotherapy.
During a 7-year period, venom immunotherapy has been stopped in 57 patients because of a fall in IgE antibody titers to insignificant levels (RAST less than 10% STD). All patients had a history of venom anaphylaxis and elevated venom-specific IgE before therapy. Maintenance doses of 50 micrograms were administered every 4 to 6 weeks; 30 patients received yellow jacket venom, and 16 patients received honeybee venom only. Therapy was stopped after treatment from 1 to 8 years (mean 2.8 years). Repeat skin tests demonstrated an average two-log decrease in sensitivity; 35 of 55 tests remained positive at venom concentrations of less than or equal to 0.1 micrograms/ml. There were 55 re-stings in 24 patients, occurring from 3 months to 5 years after cessation of therapy, resulting in three systemic reactions. One patient, previously treated with bee venom, reacted to a yellow jacket sting. These re-sting reactors also had tolerated several other stings after therapy was stopped. Thus, the two actual reactions represent a "failure" rate of 8% per patient and 4% per sting, compared to reaction rates of 27% and 17% in patients who stopped therapy without physician advice. These data suggest that this criterion may be reliable for stopping therapy. However, subsequent tolerated re-stings may require continued patient evaluation.
Adolescent↗
Local intranasal immunotherapy with high-dose polymerized ragweed extract.
Thirty-one ragweed-allergic patients received preseasonal local intranasal immunotherapy (LNIT) with high doses of gluteraldehyde-polymerized ragweed extract (average total dose 544 micrograms antigen E). Minimal side effects were reported during treatment and did not interfere with the dosing schedule. During the ragweed pollen season, LNIT-treated patients had lower symptom scores for sneezing, rhinorrhea and nasal congestion than a comparable group of untreated ragweed-allergic patients. There was no difference in ragweed-induced eye symptoms between the two groups. Secretory ragweed-specific IgA and IgG rose following LNIT treatment. Absolute antibody titers and changes in titers did not correlate with clinical improvement. LNIT with the polymerized ragweed did not block the seasonal rise in serum ragweed-specific IgE. These results suggest that LNIT with high-dose polymerized ragweed extract is a safe, simple and effective form of immunotherapy.
Adult↗
Stinging insect allergy: progress and problems.
Explore the source record for details and available documents.
Humans↗
Stinging insect allergy: natural history and modification with venom immunotherapy.
The natural history of stinging insect allergy and its modification by venom immunotherapy was investigated by follow-up observations of patients with histories of venom anaphylaxis and detectable venom-specific IgE. The patients were divided into three categories: (1) receiving venom immunotherapy, (2) declined venom immunotherapy, and (3) terminated venom immunotherapy. One hundred twenty-seven patients were evaluated after 6 mo to 9 yr of venom immunotherapy. Most received top venom doses of 50 micrograms of yellow jacket and/or honeybee venoms every 4 wk. There were 87 restings in 48 patients resulting in two systemic reactions, only one of which could be considered a treatment failure (1%). Fifty-six patients never received venom immunotherapy. In this group there were 40 restings in 28 patients with 14 systemic reactions (35%). In 88 patients who stopped venom immunotherapy, 61 restings in 41 patients led to 11 systemic reactions (17%). Patients with cardiovascular/or respiratory symptoms with initial sting anaphylaxis were at risk for subsequent reactions. With one exception, patients with hives and edema only as the initial reaction either had a similar or no reaction when they were restung. These results confirm the efficacy of venom immunotherapy but also suggest that there are factors other than the presence of venom-specific IgE modulating the occurrence of clinical anaphylaxis.
Adolescent↗