Food, drug, insect sting allergy, and anaphylaxis
Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: Importance of baseline serum tryptase—a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity

https://doi.org/10.1016/j.jaci.2009.08.027Get rights and content

Background

Severe anaphylaxis to honeybee or vespid stings is associated with a variety of risk factors, which are poorly defined.

Objective

Our aim was to evaluate the association of baseline serum tryptase concentrations and other variables routinely recorded during patient evaluation with the frequency of past severe anaphylaxis after a field sting.

Methods

In this observational multicenter study, we enrolled 962 patients with established bee or vespid venom allergy who had a systemic reaction after a field sting. Data were collected on tryptase concentration, age, sex, culprit insect, cardiovascular medication, and the number of preceding minor systemic reactions before the index field sting. A severe reaction was defined as anaphylactic shock, loss of consciousness, or cardiopulmonary arrest. The index sting was defined as the hitherto first, most severe systemic field-sting reaction. Relative rates were calculated with generalized additive models.

Results

Two hundred six (21.4%) patients had a severe anaphylactic reaction after a field sting. The frequency of this event increased significantly with higher tryptase concentrations (nonlinear association). Other factors significantly associated with severe reactions after a field sting were vespid venom allergy, older age, male sex, angiotensin-converting enzyme inhibitor medication, and 1 or more preceding field stings with a less severe systemic reaction.

Conclusion

In patients with honeybee or vespid venom allergy, baseline serum tryptase concentrations are associated with the risk for severe anaphylactic reactions. Preventive measures should include substitution of angiotensin-converting enzyme inhibitors.

Section snippets

Study design

The Tryptase in Hymenoptera Venom Allergy study of the EAACI Interest Group on Insect Venom Hypersensitivity is a partly retrospective and partly prospective observational cohort study performed in 14 European clinics specializing in the diagnosis and treatment of allergic diseases. The study consists of 3 parts and evaluates patients with Hymenoptera venom allergy who were enrolled consecutively and prospectively. Part I of the study is a retrospective analysis addressing the importance of

Clinical characteristics of the cohort

One thousand forty-three subjects were originally enrolled in the study. In compliance with the exclusion criteria, 962 hitherto untreated patients were available for the evaluation of reactions associated with the index field sting and of their predictive variables. Mean patient age in that cohort was 38.2 ± 16.9 years; the majority of patients were male (54.4%) and had vespid venom allergy (70.0%). Some (9.9%) of the patients had already had 1 or more preceding, less severe systemic sting

Discussion

Our study is the first to evaluate the importance of BTCs in the serum and of a variety of other suspected risk factors for past severe systemic reactions after a field sting in untreated subjects. The only other epidemiologic study to which our study can be compared is the North American Hymenoptera Venom Study, which was purely descriptive, could not consider tryptase concentrations, and might not have been able to exactly diagnose the type of insect allergy because of diagnostic shortcomings

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    Supported by grants for the collection of the data from Phadia (Freiburg, Germany) and ALK-Abelló (Wedel, Germany).

    Disclosure of potential conflict of interest: F. Ruëff has received lecture honoraria from ALK-Abelló, Phadia, Bencard, and HAL and has received research support from Allergopharma and HAL. B. Przybilla has received research support from Informationsverbund Dermatologischer Kliniken and has provided legal consultation or expert witness testimony on the topic of occupational dermatoses. M. B. Biló has received lecture honoraria from Stallergenes. F. Scheipl has received research support from Deutsche Forschungsgemeinschaft. W. Aberer has received lecture honoraria from ALK-Abelló, Phadia, and Bencard. A. Bodzenta-Lukaszyk and I. Kucharewicz have received honoraria from HAL. F. Bonifazi has received lecture honoraria from Phadia. T. Hawranek has received lecture honoraria and research support from ALK-Abelló. N. Reider has received lecture honoraria and research support from ALK-Abelló, HAL, Bencard, and Phadia. G. J. Sturm has received lecture honoraria from ALK-Abelló. The rest of the authors have declared that they have no conflict of interest.

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