In insect sting allergy, most of the modern dilemmas associated with
immunology, pathophysiology, diagnosis and treatment of IgE-mediated
anaphylactic reactions are evident.
Hymenoptera Venom Allergy
EAACI Interest Group
In insect sting allergy, most of the modern dilemmas associated with
immunology, pathophysiology, diagnosis and treatment of IgE-mediated
anaphylactic reactions are evident. All controversial issues related
to allergic diseases can be addressed within the field of Hymenoptera
venom allergy, e.g.: What makes an allergen to act as an allergen? Who
is at risk to get sensitised and to sustain severe reactions? Who
needs immunotherapy? What are the risk factors for a poor outcome (in
untreated or in treated patients)? How long does the protective effect
of immunotherapy last?
Even if we still do not know how venom immunotherapy (VIT) works, we
can state that it is probably the most effective form of
immunotherapy, which is currently available. VIT is safe and it does
protect patients from later anaphylactic sting reactions thereby
improving the patients’ quality of life.
The most recent epidemiological studies continue to reveal that a
substantial number of patients with insect sting anaphylaxis, who are
admitted to an emergency department had a history of a previous
allergic sting reaction. Nevertheless, these patients who were known
to be at risk, had not been provided with an emergency kit including
auto-injectable epinephrine, and VIT had not been recommended before.
This finding indicates a poor awareness of the disease and of the
available treatment options not only in the general population, but
also among health care workers.
The aims of the Interest Group on Hymenoptera Venom Allergy are:
• To promote the knowledge on epidemiology, natural history and risk
factors of insect venom allergy.
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• To study new strategies for VIT.
• To endorse further investigation on the immunological mechanisms of
the early and long-term efficacy of VIT.
• To increase the safety of specific immunotherapies and to provide
safer criteria for stopping them.
The current Hymenoptera Venom Allergy board includes:
Chairman: M.Beatrice Bilò
Secretary: Franziska Ruëff
Members who actively contributed to the last studies: Aberer Werner,
Birnbaum Joëlle, Bodzenta-Lukaszyk Anna, Bonifazi Floriano, Bucher
Christoph, Campi Paolo, Darsow Ulf, Egger Cornelia, Haeberli
Gabrielle, Hawranek Thomas, Körner Michael, Kucharewicz Iwona, Lang
Roland, Müller Ulrich, Przybilla Bernhard, Quercia Oliviero, Reider
Norbert, Severino Maurizio, Sticherling Michael, Sturm Gunter,
Wüthrich Brunello
Related current European projects
Recently, a large prospective observational study was executed by the
Interest Group on Insect Venom Hypersensitivity. The study was
performed in 14 European departments specialised on the diagnosis and
treatment of allergic diseases. The Tryptase in Hymenoptera Venom
Allergy Study (TIHVA) examined risk factors for severe sting reactions
and for significant side effects during VIT. These parts of the study
have been submitted for publication. A third part of the study is
still ongoing. This aspect aims to examine the outcome of VIT by
analysing sting reactions in patients on and after VIT.
Other scientific activities
Proposals of Task forces
• Task force “Sting challenge test”. We intend to update the position
paper (Ruëff F, Przybilla B, Müller U, Mosbech H. The sting challenge
test in Hymenoptera venom allergy. Allergy 1996; 51:216-225). Those
who are interested in an active contribution please contact Franziska
Ruëff (This email address is being protected from spambots. You need
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• Task force “Self medication of anaphylactic reactions”. We intend to
update the position paper (Müller U, Mosbech H, Blaauw P, Dreborg S,
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Malling HJ, Przybilla B, Urbanek R, Pastorello E, Blanca M, Bousquet
J, Jarisch R, Youlten L. Emergency treatment of allergic reactions to
Hymenoptera stings. Clin Exp Allergy 1991; 21:281-288). Those who are
interested in an active contribution please contact M.Beatrice Biló
(This email address is being protected from spambots. You need
JavaScript enabled to view it. document.getElementById('cloak1b3dc3b51
22fcd9b7ae177dead6a955c').innerHTML = ''; var prefix = 'ma' + 'il' +
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Planned studies
• Venom immunotherapy despite contraindication (beta-Blocker, ACEinhibitors, malignant or autoimmune diseases). Those who are
interested in an active contribution please contact Franziska Ruëff
(This email address is being protected from spambots. You need
JavaScript enabled to view it. document.getElementById('cloak5fe829c80
a2974e7a49de4419ae2a4fc').innerHTML = ''; var prefix = 'ma' + 'il' +
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• Protective effect of VIT after treatment stop. Prospective
observational multi-centre study. Those who are interested in an
active contribution please contact M. Beatrice Biló (This email
address is being protected from spambots. You need JavaScript enabled
to view it. document.getElementById('cloak324397cba22707a5e5746d8f4fab
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Related events
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Past congresses
The XXVII EAACI Congress took place in Barcelona last June and
embraced numerous sessions in the field of Hymenoptera Venom Allergy:
Post Graduate Courses, Breakfast seminars, Workshop and Oral
Communications Sessions.
Upcoming congresses
The XXVIII EAACI Congress will take place from June 6 – 10, 2009, in
Warsaw, Poland. Numerous Insect Venom Allergy events are included in
the programme, such as:
Saturday, 6 June 2009: Post Graduate Course
• Prevalence of Hymenoptera venom allergy in the general population.
• Cross-reactivity between plant and insect glycoproteins.
• Improving the diagnosis of venom allergy.
• Mechanisms of venom immunotherapy protection.
• Discontinuing venom immunotherapy.
• Recombinant allergens and insect venom hypersensitivity.
Sunday, 7 June 2009: Venom Hypersensitivity Interest Group - Business
Meeting and Session
Pro & Con - Prolonging Interval between VIT Injections: is it safe and
effective?
Monday, 8 June 2009: Workshop: What’s new in Venom Hypersensitivity
• Cardiovascular diseases and insect sting anaphylaxis.
• Mast cell diseases and insect sting allergy.
• Venom immunotherapy in Hymenoptera venom allergic patients with
immunologic diseases and neoplasms.
Monday, 9 June and Tuesday, 8 June: Oral Communication Sessions, and
Poster Presentation sessions
Wednesday, 10 June 2009: Pro & Con session
IgE Negative Anaphylaxis after Hymenoptera Stings: Does it Really
Exist?
World Allergy Congress. December 06 –10, 2009, Buenos Aires, Argentina
Main topics: Epidemiology of Venom Anaphylaxis, Regional aspects of
Venom Allergy, Venom immunotherapy in Clinical Practice, VIT with
recombinant compounds.
Allergy School in Ancona (Italy), September 3 – 6, 2009
This is the 1st EAACI & GA2LEN Allergy School in Hymenoptera Venom
Allergy. The aim of this Allergy School is to educate young physicians
from all over the Europe who are interested in the diagnosis and
treatment of children and adults with Hymenoptera venom allergy. The
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Course will include lectures, which communicate basic and advanced
knowledge (epidemiology, risk factors, frequent and rare clinical
manifestations, diagnostics, indication for treatment, procedure of
treatment, efficacy, duration of treatment), interactive practical
demonstrations (entomology of Hymenoptera, skin tests and ultra-rush
immunotherapy) and discussion of difficult clinical cases.
Must read recent Journal Articles
1. González de Olano D, Alvarez-Twose I, Esteban-López MI, et al.
Safety and effectiveness of immunotherapy in patients with indolent
systemic mastocytosis presenting with Hymenoptera venom anaphylaxis. J
Allergy Clin Immunol. 2008;121:519-26.
This study demonstrates that venom immunotherapy is effective to treat
IgE-mediated Hymenoptera anaphylaxis in patients with mastocytosis.
According to the authors, VIT use is recommended despite a relatively
high risk of adverse reactions during the build-up phase, because VIT
provides protection from anaphylaxis in around 3/4 of the patients.
2. Golden DB, Kelly D, Hamilton RG, Wang NY, Kagey-Sobotka A. Dialyzed
venom skin tests for identifying yellow jacket-allergic patients not
detected using standard venom. Ann Allergy Asthma Immunol.
2009;102:47-50.
The results of this study suggest that dialyzed venom may improve the
ability of skin tests to detect yellow jacket allergy.
3. Müller UR, Johansen N, Petersen AB, Fromberg-Nielsen J, Haeberli G.
Hymenoptera venom allergy: analysis of double positivity to honey bee
and Vespula venom by estimation of IgE antibodies to species-specific
major allergens Api m1 and Ves v5. Allergy 2009;64:543-8.
In patients with hymenoptera venom allergy, diagnostic tests are often
positive for honey bee and Vespula venom causing problems in the
selection of venoms for immunotherapy. The possibility to detect IgEantibodies which correspond to species-specific recombinant major
allergens (Api m1 for bee venom and Ves v5 for Vespula venom) may
improve the diagnosis.
4. Severino MG, Cortellini G, Bonadonna P, et al. Sublingual
immunotherapy for large local reactions caused by honeybee sting: a
double-blind, placebo-controlled trial. J Allergy Clin Immunol
2008;122:44-8.
This study shows that honeybee SLIT reduces the extent of LLRs, with a
good safety profile. According to the authors, this proof-of-concept
study suggests that SLIT deserves further investigation in hymenoptera
allergy, and that trials involving systemic reactions and dose-ranging
studies are needed.
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5. Ruëff F, Bilò MB, Jutel M et al. Interest group on Hymenoptera
venom allergy of the European Academy of Allergology and Clinical
Immunology. Sublingual immunotherapy with venom is not recommended for
patients with Hymenoptera venom allergy. J Allergy Clin Immunol.
2009;123:272-3.
This letter expresses the position of the Interest Group of the EAACI
on Hymenoptera venom allergy with respect to the potential use of
sublingual immunotherapy in the field of venom allergy, for which an
effective and safe subcutaneous form of immunotherapy is already
available.
6. White KM, England RW. Safety of angiotensin-converting enzyme
inhibitors while receiving venom immunotherapy. Ann Allergy Asthma
Immunol. 2008;101:426-30.
This study suggests that there is not an association between ACE-I use
and increased frequency of systemic reactions to venom immunotherapy.
7. Bilò BM, Bonifazi F. Epidemiology of insect-venom anaphylaxis. Curr
Opin Allergy Clin Immunol. 2008;8:330-7.
A comprehensive review of the epidemiology, natural history and risk
factors of insect-venom allergy, focusing on the recent research on
these aspects of Hymenoptera-sting anaphylactic reactions.
8. Diwakar L, Noorani S, Huissoon AP, Frew AJ, Krishna MT. Practice of
venom immunotherapy in the United Kingdom: a national audit and review
of literature. Clin Exp Allergy. 2008;38:1651-8.
This study underlines that currently there is considerable variation
in the diagnosis and management of hymenoptera venom allergy in the
United Kingdom, demonstrating that the current international
guidelines for the diagnosis and management of hymenoptera venom
allergy are not being followed by UK allergy practitioners.
9. Bonadonna P, Perbellini O, Passalacqua G et al. Clonal mast cell
disorders in patients with systemic reactions to Hymenoptera stings
and increased serum tryptase levels. J Allergy Clin Immunol 2009;
123:680-6
44 of 379 consecutive patients (11.6 %) with systemic sting reactions
had increased baseline serum tryptase levels (>11.4 µg/l). Bone marrow
biopsy was performed in 34 subjects with increased trpytase level. The
diagnosis was indolent systemic mastocytosis in 21 (61.7%) of 34
subjects and monoclonal MC activation syndrome in 9 (26.5%) of 34
subjects. Thus, 5.5 % of consecutive patients with insect sting
anaphylaxis were identified to have systemic mastocytosis.
10. Oude Elberink JN, van der Heide S, Guyatt GH, Dubois AE.
Immunotherapy improves health-related quality of life of adult
patients with dermal reactions following yellow jacket stings. Clin
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Exp Allergy. 2009 Apr 2. Epub ahead of print
This study underlines that venom immunotherapy results in a clinically
significant improvement of health-related quality of life (HRQL) in
most patients with reactions limited to the skin following yellow
jacket stings. Prescription of an EpiPen in patients not choosing this
treatment is associated with deterioration in HRQL and should
therefore be avoided as definitive treatment in these patients.
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