467 Clinical Case. Bee Venom Anaphylaxis

BACKGROUND: Skin testing remains the principal confirmatory test for sensitization to hymenopteravenoms. Mechanisms on how venom induces vascular permeability in the skinfollowing intradermal testing are elucidated and how tolerance is induced followinghigh-dose venom exposure. For management, venom immunotherapy remains the mosteffective treatment. Use of immunotherapy in large local reactors to reduce morbidity is discussed. Baseline serum tryptase levels have been identified as one potential markerfor severe systemic reactions to a subsequent sting. Bee venom immunotherapy is effective in most patients immediately after the conventionalmaintenance dose has been reached. In the minority of patients who are not protected withthis dose, an increased maintenance dose will provide appropriate protection immediately after itis achieved usually by 3 to 6 months withstandarding protocols. Thus, the dosage of the maintenance dose seems to be the major factor affectingprotection from re-stings rather than the accumulated venom dose or the durationon the Maintenance Dose. A rush protocol would be recommendedif the patient's risk of being stung againbefore standard immunotherapy could work wereconsidered high. Although immunotherapy is oftenadministered by allergists, it may be deliveredby any practitioner who is willing to observe the patientand to treat anaphylaxis if it should occur. METHODS: A 17-year-old man reported being stung by a bee in his workplace. He had been stung several times before, with no clinical manifestations. This last time, he developed face edema, respiratory distress, dyspnea, vomiting recieveing treatment with hydrocortisone. Some time later, he was stung another time, presenting more severe symptoms including dyspnea, stridor, altered mental status, hives, so he was taken to a local clinic where he received epinephrine, dextrose, was hospitalized 4 hours until clinical remission. How should his case be managed subsequently? RESULTS: Intradermal test was positive with a dilution 1:200000. CONCLUSIONS: For patients with a clear history of anaphylaxis such as the one described in the vignette, information should be provided on avoidance and on the use of emergency treatment with epinephrine auto-injectors. Patients should be advised to carry an auto-injector and to wear a medical alert bracelet.