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PubMed2006

ICD-9-CM coding of emergency department visits for food and insect sting allergy.

PURPOSE: Little is known about the role of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for identification of specific allergic reactions in the emergency department (ED). METHODS: Investigators in 10 EDs reviewed 1395 charts of consecutive patients presenting with food allergy (ICD-9-CM codes 693.1 and 995.60 to 995.69) and insect sting allergy (code 989.5). They also reviewed charts of patients with "unspecified" allergic reactions (codes 995.0 [other anaphylactic shock] and 995.3 [allergy, unspecified]) to identify additional patients with food or insect sting allergy. RESULTS: Of 406 patients with food allergy, 216 patients (53%) were coded as food allergy, whereas the remaining 190 patients (47%) were not. Of 394 patients with insect sting allergy, 341 (87%) were coded as insect sting allergy, whereas 53 patients (13%) were not. Characteristics of ICD-9-CM-identified compared with chart-review-identified patients differed for both food and insect sting allergy. ICD-9-CM-identified patients with food allergy were less likely to experience anaphylaxis. CONCLUSIONS: Almost half the patients with food allergy would have been missed by using food-specific ICD-9-CM codes alone, whereas only 13% of patients with insect sting allergy would have been missed. Furthermore, characteristics of these allergy patients would have been biased by studying only patients identified by using the allergen-specific ICD-9-CM codes.

Adult↗

PubMed1992

Stinging insect allergy.

Insect sting anaphylaxis is a relatively common problem estimated to affect at least 0.4% of the population and is responsible for at least 40 deaths per year in the United States. The allergic reactions are mediated by IgE antibodies directed at constituents in honeybee, yellow jacket, hornet, and wasp venoms. In addition, increasing numbers of reactions occur from fire ant stings, non-winged Hymenoptera present in the Southeastern United States. The anaphylactic symptoms are typical of those occurring from any cause. Most reactions in children are mild, frequently involving dermal manifestations (hives, edema) only. The more severe reactions, such as shock and loss of consciousness, can occur at any age but are relatively more common in adults. Following sting anaphylaxis, approximately 50% of unselected patients will continue to have allergic reactions to subsequent stings. The natural history of the disease process is influenced by the severity of the anaphylactic symptoms. Children with dermal reactions only have a benign course and are unlikely to have recurrent reactions. Patients with more severe reactions are at risk for repeat anaphylaxis. Patients with a history of insect sting anaphylaxis and positive venom skin tests should have epinephrine available and are candidates for subsequent venom immunotherapy, which provides almost 100% protection against subsequent re-sting reactions. Recommendations for the duration of immunotherapy are evolving. Venom therapy can be stopped if skin test reactions become negative. For most patients, 3 years of therapy appears adequate, despite persistence of positive venom skin tests.

Animals↗

PubMed1996

ED management of insect stings.

Allergic reactions to insect stings are a common and sometimes serious medical problem. Although most reactions to stinging insects are mild, a pool of individuals in the general population has experienced or will manifest an anaphylactic reaction to stings. Concern has been heightened with the introduction of stinging species not indigenous to the United States which have a proclivity for stinging frequently. The emergency physician needs to understand the pathophysiology of insect sting anaphylaxis, recognize its onset, and formulate an appropriate pharmacological treatment plan. In addition, the emergency physician must instruct the patient on avoidance of insects and on outpatient use of epinephrine. For the patient who truly has had an anaphylactic event, referral to an allergist is imperative.

Anaphylaxis↗

PubMed2006

Management of stinging insect hypersensitivity: a 5-year retrospective medical record review.

BACKGROUND: The Joint Task Force on Practice Parameters for Allergy and Immunology recommends that patients with a history of a systemic reaction to an insect sting be educated on ways to avoid insect stings, carry injectable epinephrine for emergency self-treatment, undergo specific IgE testing for stinging insect sensitivity, and be considered for immunotherapy. OBJECTIVE: To review frontline providers' documented care and recommendations for imported fire ant and flying insect hypersensitivity reactions. METHODS: A retrospective medical record review was performed of emergency department and primary care clinic visits between November 1, 1999, and November 30, 2004. Using International Classification of Diseases, Ninth Revision, codes, medical records were selected for review to identify patients with potential insect hypersensitivity. RESULTS: A total of 769 medical records from patients who experienced an insect sting were reviewed. Of 120 patients with a systemic reaction, 66 (55.0%) received a prescription for injectable epinephrine, and 14 (11.7%) were given information regarding avoidance of the offending insect. Forty-seven patients with systemic reactions (39.2%) were referred to an allergist. Of 28 patients who kept their appointments and underwent skin testing, 3 had negative results and 25 (89%) had positive results and were advised to start immunotherapy. CONCLUSION: Adherence to the stinging insect hypersensitivity practice parameter recommendations is poor. Many patients who have experienced a systemic reaction after an insect sting and have sought medical care are not afforded an opportunity for potentially lifesaving therapy.

Adolescent↗

PubMed1999

In vivo histamine release during the first minutes after deliberate sting challenges correlates with the severity of allergic symptoms.

In this study, deliberate sting challenge was investigated as a method for estimating the severity of anaphylactic reactions in bee venom-sensitized subjects. Twenty-one patients with previous anaphylactic reactions to field bee sting were subjected to a deliberate sting challenge (n = 32). To document anaphylactic reactions, plasma histamine levels were measured before, and then 1 and 2 min after, bee sting challenge. Eleven patients were re-challenged after 3-5 weeks. On 18 occasions, sting challenges caused no systemic reactions, in seven cases reactions were mild, in five moderate and in two severe. In all children showing systemic reactions, significant increases of plasma histamine were measured after 2 min. The results correlated significantly with clinical scores but not with skin prick test or with specific immunoglobulin E (IgE) and immunoglobulin G (IgG) antibodies against bee venom. In patients developing local reactions only, no increase of plasma histamine was detected. The relative amount of released histamine correlated significantly with the severity of clinical symptoms. Significant histamine release occured during the first 2 min after sting challenge in children with subsequent systemic reactions and the severity of these subsequent anaphylactic reactions correlated with plasma histamine concentrations. The measurement of plasma histamine levels in the first minutes after challenge test may therefore be used as an objective marker of a potential systemic reaction.

Adolescent↗

PubMed1998

Cutaneous manifestations of the Hemiscorpius lepturus sting: a clinical study.

BACKGROUND AND DESIGN: Scorpion stings are a serious problem in Khuzestan, a southwestern province of Iran. In around 5 years, 36,463 patients with scorpion stings have been seen. Most of the patients had no cutaneous findings, but a small group of patients developed various local and generalized skin manifestations. Patients were evaluated in terms of cutaneous findings early in and during the course of their illness. The correlation between the site of the sting and the severity of the cutaneous and systemic problems is discussed. RESULTS: Hemiscorpion (Hemiscorpius) lepturus (HL), which is responsible for more than 10% of the scorpion stings in this area, was found to be the only scorpion with related cutaneous findings. Different species of the Buthidae family, which were responsible for the remaining 90% of scorpion stings, have a neurotropic and noncytotoxic venom and, as a result, induce no cutaneous reaction. CONCLUSIONS: HL venom is cytotoxic, and HL is the only scorpion whose venom induces a toxic reaction. Erythema, purpuric changes, bullae, necrosis, and ulcers, or a combination of these, may be seen at different stages. The site and the severity of the cutaneous reaction may aid in the prediction of the clinical outcome for the patients and in estimating the interval between the sting and presentation.

Adolescent↗

PubMed1986

Insect bites and stings: managing allergic reactions.

This article concerns itself with three common reactions (local, toxic and anaphylactic) resulting from insect or arthropod bites and stings. A local reaction consists of sharp, localized pain followed by a reddening at the site, which usually resolves itself in 24 hours. A toxic reaction may include gastrointestinal symptoms, fever, headache, dizziness or convulsions, often following an episode of multiple stings. An anaphylactic reaction may be mild (hives, itching) or severe (systemic reactions including airway and cardiovascular symptoms). Even though most bites and stings are not serious, nurse practitioners should be aware of potential death resulting from insect sting allergy. They should teach hypersensitive patients, or patients with a history of a systemic reaction to any agent, about prophylactic measures. Tables showing the characteristics of insects that cause cutaneous lesions in humans, and measures necessary to decrease the risk of being stung, can be used as learning tools to prevent insect sting allergy. Because of the rapid onset of anaphylaxis, life-saving measures include awareness in persons who are hypersensitive, emergency preparedness and preventing bites and stings from occurring.

Aminophylline↗

PubMed2006

Emergency treatment and prevention of insect-sting anaphylaxis.

PURPOSE OF REVIEW: Hymenoptera stings are thought to cause systemic allergic reactions in 0.4-5% of individuals, and to account for 40-100 deaths annually in the USA. This review examines current research on insect-sting anaphylaxis in the emergency department (ED), and provides suggestions on how to improve ED treatment and prevention. RECENT FINDINGS: Few published studies since January 2005 examine the emergency management of insect-sting allergic reactions. Earlier studies found that few ED patients with this problem received health education, a prescription for self-injectable epinephrine or referral to an allergy specialist at ED discharge. A recent multicenter study by our group demonstrated that ED patients with insect-sting allergic reactions continue to receive care discordant with national guidelines for the emergency management of anaphylaxis. SUMMARY: Concordance with national guidelines for the treatment of anaphylaxis remains poor among insect-sting allergy patients. The development of a simple, clinical definition of anaphylaxis is urgently needed to facilitate identification of cases. Such a definition would help tremendously with dissemination of emergency management guidelines and the creation of systems for their implementation. All of these steps are essential for the improved treatment and prevention of insect-sting anaphylaxis in the ED.

Anaphylaxis↗

PubMed2005

[Anaphylaxis to hymenoptera sting: study of 113 patients].

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe the clinical and epidemiological features of anaphylactic reactions to hymenoptera stings, with a case-history analysis according to severity. PATIENTS AND METHOD: We conducted an observational descriptive study of patients aged between 10 and 80 years who suffered a systemic reaction after hymenoptera sting. All of them showed specific serum IgE to venoms from Apis, Vespula and/or Polistes. A questionnaire including history of atopy, past reactions and characteristics of the reaction, was performed by individual interview. Anaphylactic reactions were classified into two levels of severity according to Müller's classification. An analysis of independence was carried out in order to relate each level with several factors: age, gender, atopy, type of previous reactions, area of sting and time sequence. RESULTS: 113 patients were included (63 male; mean age [standard deviation]: 40.1 [15.9] years). Reactions were accounted for bee venom in 10.6% of patients, and wasp in 89.4%. Specific IgE was positive to Vespula in 91.9% of subjects, Polistes in 71.4%, and Apis in 28.7%. Furthermore, 50.4% were sensitive to both Vespula and Polistes. Personal history of atopy was found in 20.3%. Among the 106 patients who reminded previous stings, local large reactions were referred by 35.9% and systemic reactions by 16.5%. Upper limb was the most frequent area of sting (38.9%). Most common symptoms were: pruritus (77.8%), hives (57.5%), edema (54.8%), erythema (52.2%), dizziness (51.3%) and dyspnea (49.5%). Severe reactions occurred in 65.5% of patients. Age, gender, atopy, type of previous reactions, area of sting and restoration time were not significantly associated with severity. Time elapsed to first symptom was proportionally shorter in severe cases (p < 0.05). CONCLUSIONS: There is a high frequency of hypersensitivity to wasp venom (Vespula) in the studied population. Except for immediacy, severity-associated data could not be established.

Adolescent↗

PubMed1995

Anaphylactic reactions to bee-sting challenges in allergic children are not modified by endogenous catecholamines.

To investigate the role of basal catecholamine levels and the response of the adrenergic system to expected bee stings, plasma catecholamines were measured before and 1 and 2 min after bee-sting challenges. Twenty-one children (aged 4-15 y) with bee-sting allergies were selected for sequential challenges to establish the need for venom immunotherapy. The time interval between the challenges varied from 2 to 6 wk. Epinephrine, norepinephrine, and dopamine plasma levels were measured using a simultaneous single-isotope radioenzymatic assay. On the first challenge, 33% of the children experienced a normal local reaction, 29% a large local reaction, and 38% a systemic reaction. On the second challenge in 18 out of 21 subjects, 67% experienced a normal normal local reaction, 22% a large local reaction, and 11% a systemic reaction. Epinephrine and norepinephrine plasma levels increased significantly on the first and second challenges. Dopamine plasma levels showed a significant increase on the first challenge only. Plasma catecholamine levels after the second challenge revealed a significant positive correlation between epinephrine increases measured 1 and 2 min after the challenge and the concomitant sting reaction. Basal epinephrine, norepinephrine, and dopamine plasma levels did not differ significantly between patients who experienced different types of sting reactions. Based on our data, we conclude that clinical reactions to in-hospital insect-sting challenges are not affected by early increases in plasma catecholamine levels produced by the expected stress situation.

Adolescent↗

PubMed2004

Scorpion sting syndrome in a general hospital in Saudi Arabia.

OBJECTIVE: To evaluate the incidence of scorpion stings and to draw the attention of clinicians, concerning the dilemma of scorpion sting syndrome and its management in the Kingdom of Saudi Arabia (KSA). METHODS: In a retrospective survey, 251 cases were presented with scorpion stings to the Emergency Department of the Armed Forces Hospital, Riyadh, KSA during a period of 15 years (April 1986 to April 2000). Their ages ranged from 2 months to 101 years (male to female ratio was 2.6:1) and 70.6% of the cases were under 20 years of age. RESULTS: The mean annual incidence of the scorpion sting in the month of May was 16.7%, with the highest mean percentage of approximately 36% each year. The seasonal sting cycle showed the highest record was in the summer period (51%) as compared to the lowest winter period (10%). Local pain was the primary presenting complaint (95%), with a total systemic toxicity of 78.3% and 35.2% of these were children. Hypertension, sweating, salivation and tachycardia were the most common signs of systemic symptoms. The majority of patients received analgesia, local anesthetics, and application of ice and a period of observation dictated by clinical findings. Eighty-two patients (32.6%) had signs of serious envenoming, requiring admission. There were no deaths. All of these cases were mainly treated symptomatically. CONCLUSION: The beneficial effect of antivenom in protecting victims against scorpion stings is still questionable. The higher risk groups of systemic toxicity were either those with ages less than 10 years or greater than 50 years, being more susceptible due to their decreased physiologic reserves and increased debilitation.

Adolescent↗

PubMed2006

Bilateral cerebellar infarction: a rare complication of scorpion sting.

INTRODUCTION: Complications following scorpion sting are common in India and can be fatal. Stroke following scorpion sting is a rare complication and can occur by various mechanisms such as hypertension, hypotension, DIC, myocarditis and venom-induced vasculitis. We present a rare case of extensive cerebellar infarction following scorpion sting, which has rarely been reported in medical literature. OBJECTIVES: To study the clinical profile of two patients presenting with an acute onset of cerebellar symptoms following a scorpion sting. To evaluate the possible causes of the stroke and to study the relation of their symptoms to the scorpion sting. METHODS: Two young women presented with a history of acute onset of dysarthria, ataxia and incoordination following scorpion sting. They did not have any known risk factors for stroke. They had cerebellar type of dysarthria and cerebellar signs on both sides along with incoordination. A CT-scan of the brain showed bilateral extensive cerebellar infarctions. They were investigated for other causes of stroke without any positive results. With treatment the patients made a gradual but complete recovery. CONCLUSION: Since there was no evidence of hypertension, hypotension, myocarditis or disseminated intravascular coagulation, we can conclude that the patients had suffered a thrombotic stroke caused by the vasculotoxic action of the scorpion venom.

Acute Disease↗

PubMed1984

Allergens in hymenoptera venom XII: how much protein is in a sting?

The protein content of insect venoms was determined using a Coomassie blue dye binding assay as well as the Lowry phenol assay. The Lowry method tended to give excessively high values with many of the venoms because of the presence of low molecular weight phenolic compounds and other interfering substances. Using the dye binding method honey bee stings were found to contain 59 +/- 7 micrograms of protein, bumblebee and carpenter bee stings from 10 to 31 micrograms, yellow jacket stings from 1.7 to 3.1 micrograms, white faced hornet stings 2.4 to 5.0 micrograms and paper wasp stings from 4.2 to 17 micrograms protein. This is in good agreement with the value of 50 micrograms previously estimated for honey bee stings and is the first reported data for the other species.

Allergens↗

PubMed1994

Insect sting allergy: analysis of a cohort of patients who initiated venom immunotherapy from 1978 to 1986.

BACKGROUND: The proper duration of venom immunotherapy remains uncertain. OBJECTIVE: We report our experience with a cohort of patients who started venom immunotherapy from 1978 to 1986. METHODS: In a midwestern allergy practice, the cohort of 204 stinging insect-allergic patients who commenced venom immunotherapy from 1978 to 1986 were identified and evaluated by retrospective chart analysis and patient telephone inquiry. RESULTS: Only 12 patients remain on venom treatment. The majority of patients have discontinued venom immunotherapy either by self-determination (35 patients) or upon physician advice (80 patients). There was no relationship between the severity of the initial sting reaction and the length of time patients received therapy. After cessation of venom treatment, there were 148 re-stings in 117 patients with only two re-sting reactions, both of which occurred in patients with severe initial sting reactions. CONCLUSIONS: Most patients who have received four to 6 years of venom immunotherapy continue to tolerate insect stings after cessation of treatment.

Adolescent↗

PubMed1996

Risk factors associated with the severity of systemic insect sting reactions.

To evaluate risk factors associated with the severity of systemic insect sting reaction and to determine the type of insect responsible for systemic anaphylaxis, we conducted a cross-sectional study of 498 patients undergoing venom immunotherapy for insect sting reaction in 13 allergy clinics in Israel. Data were collected by questionnaire and review of patient records. Eighty percent of the patients were treated with honeybee venom, which was used as a single therapy in 60% of the group. In a multivariate logistic model the major factors identified as significantly influencing the probability of a more severe systemic reaction were short time of onset of reaction after stinging (<30 min), high number of prior stings (> or = 4), and age (> or = 18 years). A total of 79.3% of the patients had been stung outdoors, and 50% had lived all their lives in rural areas as compared to 10% in the general Israeli population. This study reports clinically valuable risk factors for the severity of systemic sting reaction. A practical finding was that the honeybee is the insect mostly responsible for sting reactions in Israel, but the type of insect is not a significant predictor of the severity of the reaction.

Adolescent↗

PubMed2003

Correlation between stinging, TEWL and capacitance.

BACKGROUND/AIMS: To study the correlation between stinging and skin barrier and to make the lactic acid stinging test much safer. METHODS: The modified lactic acid stinging test with 3% and/or 5% aqueous solution of lactic acid combined with transepidermal water loss (TEWL) and capacitance (CAP) was used. The amount of 50 microL-test material was applied on test areas, the skin of both sides nasolabial fold of 50 healthy subjects. Subjects assessed stinging basing on a 4-point scale at 0, 2.5, 5.0 and 8 min TEWL and CAP were measured at baseline and 8 min. RESULTS: The results show that the tendency of decrease in baseline CAP and increase in baseline TEWL are proportional with the increase of the sum of clinical scores (CSS). In 5% lactic acid test, negative correlation between changing ratio of TEWL (PTEWL) and clinical score at 5 min (CS5 min), and negative correlation between changing ratio of capacitance (PCAP) and CS5 min are registered. CONCLUSION: Our data indicate that there is certain relationship between the degree of stinging and the skin barrier. The stinging test method modified by lower concentration aqueous lactic acid and the assessment combined with PTEWL and PCAP is suitable for Chinese to evaluate the skin susceptibility.

Administration, Topical↗

PubMed2025

A choanoflagellate cGLR-STING pathway reveals evolutionary links between bacterial and animal immunity.

Animal innate immunity evolved from ancient pathways in bacterial anti-phage defense. How bacterial immune components were first acquired and adapted within eukaryotic cells remains poorly understood. Here we identify a complete cGLR-STING signaling axis in choanoflagellates, the closest living relatives of animals, that exhibits a mosaic of features from both bacterial and animal immunity. Comparative genomics reveals choanoflagellate cGLR and STING genes organized in operon-like arrangements reminiscent of bacterial defense loci. Reconstitution of choanoflagellate cGLR-STING signaling in vitro demonstrates that activation occurs through the conserved nucleotide immune signal 2'3'-cGAMP. Structural analysis of a choanoflagellate STING-2'3'-cGAMP complex explains how retention of bacterial-like features in early eukaryotic proteins shapes ligand specificity and receptor activation. We analyze cGLR and STING evolution in unicellular eukaryotes and identify further STING homologs in choanoflagellates and fungi that support additional independent acquisition events. Our results reveal molecular fossils that bridge bacterial and animal immunity and illuminate early eukaryotic immune system evolution.

Journal Article↗

PubMed2006

The Star STING server: a multiplatform environment for protein structure analysis.

Star STING is the latest version of the STING suite of programs and corresponding database. We report on five important aspects of this package that have acquired some new characteristics, designed to add key advantages to the whole suite: 1) availability for most popular platforms and browsers, 2) introduction of the STING_DB quality assessment, 3) improvement in algorithms for calculation of three STING parameters, 4) introduction of five new STING modules, and 5) expansion of the existing modules. Star STING is freely accessible at: http://sms.cbi.cnptia.embrapa.br/SMS/, http://trantor.bioc.columbia.edu/SMS, http://www.es.embnet.org/SMS/, http://gibk26.bse.kyutech.ac.jp/SMS/ and http://www.ar.embnet.org/SMS.

Algorithms↗