Leitlinie
Diagnose und Therapie der Bienen- und Wespengiftallergie. Positionspapier der Arbeitsgruppe Insektengiftallergie der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAI)
Diagnosis and therapy of bee and yellow jacket venom allergy
Franziska Ruëff, B. Przybilla, T. Fuchs, H. Gall, J. Rakoski, W. Stolz und D. Vieluf
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Jahrgang 24 p. 78 - 92
Abstract
Allergologie, Jahrgang 24, Nr. 2/2001, S. 78–92
Diagnose und Therapie der Bienen- und Wespengiftallergie. Positionspapier der Arbeitsgruppe Insektengiftallergie der Deutschen Gesellschaft für Allergologie und klinische Immunologie (DGAI)
Franziska Ruëff, B. Przybilla, T. Fuchs, H. Gall, J. Rakoski, W. Stolz und D. Vieluf
Klinik und Poliklinik für Dermatologie und Allergologie Ludwig-Maximilians-Universität, München
Correspondence to:
Dr. med. F. Ruëff
Klinik und Poliklinik für Dermatologie
und Allergologie
Ludwig-Maximilians-Universität
Frauenlobstraße 9 – 11
D-80337 München
Original
Guideline on diagnostic procedures for suspected hypersensitivity to beta-lactam antibiotics
Gerda Wurpts, Werner Aberer, Heinrich Dickel, Randolf Brehler, Thilo Jakob, Burkhard Kreft, Vera Mahler, Hans F. Merk, Norbert Mülleneisen, Hagen Ott, Wolfgang Pfützner, Stefani Röseler, Franziska Ruëff, Helmut Sitter, Cord Sunderkötter, Axel Trautmann, Regina Treudler, Bettina Wedi, Margitta Worm, und Knut Brockow
Volume 4 (2020) p. 11 - 43
Abstract
Allergologie select, Vol. 4/2020 (11-43)
Guideline on diagnostic procedures for suspected hypersensitivity to beta-lactam antibiotics
Gerda Wurpts1, Werner Aberer2, Heinrich Dickel3, Randolf Brehler4, Thilo Jakob5, Burkhard Kreft6, Vera Mahler7,8, Hans F. Merk1, Norbert Mülleneisen9, Hagen Ott10, Wolfgang Pfützner11, Stefani Röseler1, Franziska Ruëff12, Helmut Sitter13, Cord Sunderkötter6, Axel Trautmann14, Regina Treudler15, Bettina Wedi16, Margitta Worm17, und Knut Brockow18
1Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Germany 2Department of Dermatology, Graz Medical University, Graz, Austria, 3Department of Dermatology, Venereology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum, 4Department of Dermatology, University Hospital Münster, Münster, 5Department of Dermatology and Allergology, University Hospital Gießen und Marburg, Gießen Site, Gießen, 6Department of Dermatology and Venereology, University, Hospital Halle (Saale), Halle (Saale), 7Paul-Ehrlich Institute, Langen, 8Department of Dermatology, University Hospital Erlangen, Erlangen, 9Asthma and Allergy Centre, Leverkusen, 10Division of Pediatric Dermatology and Allergology, Auf der Bult Children’s Hospital, Hannover, 11Department of Dermatology and Allergology, University Hospital Gießen und Marburg, Marburg Site, Marburg, 12Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, 13Institute of Surgical Research, Philipps University Marburg, Marburg, 14Department of Dermatology and Allergy, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg, 15Department of Dermatology, Venereology, and Allergology and Leipzig Interdisciplinary Center for Allergology – LICA-CAC, University of Leipzig, Leipzig, 16Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, Hannover, 17Department of Dermatology, Venereology, and Allergology, Charité University Hospital Berlin, Allergy Center Charité (ACC), Berlin, and 18Department of Dermatology and Allergology am Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
This guideline on diagnostic procedures for suspected beta-lactam antibiotic (BLA) hypersensitivity was written by the German and Austrian professional associations for allergology, and the Paul-Ehrlich Society for Chemotherapy in a consensus procedure according to the criteria of the German Association of Scientific Medical Societies. BLA such as penicillins and cephalosporins represent the drug group that most frequently triggers drug allergies. However, the frequency of reports of suspected allergy in patient histories clearly exceeds the number of confirmed cases. The large number of suspected BLA allergies has a significant impact on, e.g., the quality of treatment received by the individual patient and the costs to society as a whole. Allergies to BLA are based on different immunological mechanisms and often manifest as maculopapular exanthema, as well as anaphylaxis; and there are also a number of less frequent special clinical manifestations of drug allergic reactions. All BLA have a beta-lactam ring. BLA are categorized into different classes: penicillins, cephalosporins, carbapenems, monobactams, and beta-lactamase inhibitors with different chemical structures. Knowledge of possible cross-reactivity is of considerable clinical significance. Whereas allergy to the common beta-lactam ring occurs in only a small percentage of all BLA allergic patients, cross-reactivity due to side chain similarities, such as aminopenicillins and aminocephalosporins, and even methoxyimino cephalosporins, are more common. However, the overall picture is complex and its elucidation may require further research. Diagnostic procedures used in BLA allergy are usually made up of four components: patient history, laboratory diagnostics, skin testing (which is particularly important), and drug provocation testing. The diagnostic approach – even in cases where the need to administer a BLA is acute – is guided by patient history and risk – benefit ratio in the individual case. Here again, further studies are required to extend the present state of knowledge. Performing allergy testing for suspected BLA hypersensitivity is urgently recommended not only in the interests of providing the patient with good medical care, but also due to the immense impact of putative BLA allergies on society as a whole.Correspondence to:
Dr. med. Gerda Wurpts, Clinic for Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), Uniklinik RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
Email: [email protected]
Statement
Induction of penicillin tolerance during pregnancy: Allergological opinion on the recommendation of the current AWMF Guidelines on Diagnosis and Treatment of Syphilis (AWMF Registry No. 059-002)
Bettina Wedi, Werner Aberer, Knut Brockow, Heinrich Dickel, Randolf Brehler, Thilo Jakob, Burkhard Kreft, Vera Mahler, Hans F. Merk, Norbert Mülleneisen, Hagen Ott, Wolfgang Pfützner, Stefani Röseler, Franziska Ruëff, Cord Sunderkötter, Axel Trautmann, Regina Treudler, Margitta Worm, and Gerda Wurpts
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Volume 5 (2021) p. 67 - 71
Abstract
Allergologie select, Vol. 5/2021 (67-71)
Induction of penicillin tolerance during pregnancy: Allergological opinion on the recommendation of the current AWMF Guidelines on Diagnosis and Treatment of Syphilis (AWMF Registry No. 059-002)
Bettina Wedi1, Werner Aberer2, Knut Brockow3, Heinrich Dickel4, Randolf Brehler5, Thilo Jakob6, Burkhard Kreft7, Vera Mahler8,9, Hans F. Merk10, Norbert Mülleneisen11, Hagen Ott12, Wolfgang Pfützner13, Stefani Röseler14, Franziska Ruëff15, Cord Sunderkötter16, Axel Trautmann17, Regina Treudler18, Margitta Worm19, and Gerda Wurpts20
1Department of Dermatology, Allergology, and Venereology, Comprehensive Allergy Center, Hannover Medical School, Germany, 2Department of Dermatology, Medical University Graz, Austria, 3Department and Outpatient Clinic for Dermatology and Allergology am Biederstein, Technical University of Munich, 4Department of Dermatology, Venereology, and Allergology, St. Josef-Hospital, University Hospital of the Ruhr University of Bochum, 5Department of Dermatology, University Hospital Muenster, 6Department of Dermatology and Allergology, University Medical Center Gießen and Marburg, Campus Gießen, 7Department of Dermatology and Venereology, University Hospital Halle (Saale), 8Paul-Ehrlich-Institut, Langen, 9Dermatologists at the Merckhaus Dr. Herbst and Kollegen, Darmstadt, 10Department of Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), University Hospital RWTH Aachen, 11Lung and Allergy Center, Leverkusen, 12Pediatric Dermatology and Allergology, Children’s and Youth Hospital “Auf der Bult”, Hannover, 13Department of Dermatology and Allergology, University Medical Center Gießen and Marburg, Campus Marburg, 14Augustinians Hospital, Academic Teaching Hospital of the University of Cologne, 15Department and Outpatient Clinic of Dermatology, and Allergology, Allergy Center, Hospital of the University of Munich, 16University Hospital and Outpatient Clinic of Dermatogy and Venereology, University Hospital Halle (Saale), 17Department and Outpatient Clinic of Dermatology, Venereology, and Allergology, Allergy Center Mainfranken, University Hospital Würzburg, 18Department and Outpatient Clinic of Dermatology, Venereology, and Allergology and Leipzig Interdisciplinary Allergy Center – LICACAC, University of Leipzig, 19Department for Dermatology, Venereology, and Allergology, Charité-University Medicine Berlin, Allergy Center-Charité (ACC), Berlin, 20Department of Dermatology and Allergology, Aachen Comprehensive Allergy Center (ACAC), University Hospital RWTH Aachen, Germany
Correspondence to:
Prof. Dr. Bettina Wedi, Klinik für Dermatologie, Allergologie und Venerologie, Comprehensive Allergy Center, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
Email: [email protected]
Case Report
Omalizumab ensures compatibility to bee venom immunotherapy (VIT) after VIT-induced anaphylaxis in a patient with systemic mastocytosis
Askin Gülsen, Franziska Ruëff, and Uta Jappe
Volume 5 (2021) p. 128 - 132
Abstract
Allergologie select, Vol. 5/2021 (128-132)
Omalizumab ensures compatibility to bee venom immunotherapy (VIT) after VIT-induced anaphylaxis in a patient with systemic mastocytosis
Askin Gülsen1, Franziska Ruëff2, and Uta Jappe1,3
1Interdisciplinary Allergy Outpatient Clinic, Department of Pneumology, University of Luebeck, 2Department of Dermatology and Allergology, Klinikum der Ludwig-Maximilians-Universität, Munich, and 3Division of Clinical and Molecular Allergology, Research Center Borstel, Leibniz Lung Center, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Borstel, Germany
Background: Systemic reactions and anaphylaxis due to Hymenoptera venoms occur in up to 7.5% of the European population. Fatal sting reactions are very rare. Serum tryptase levels should be measured in all patients with a history of severe reactions in order to detect mastocytosis and to determine the risk of severe reactions to venom immunotherapy (VIT). The risk to experience severe or even fatal anaphylaxis due to insect stings is quite high in patients with mastocytosis. Therefore, lifelong VIT is recommended in these highly threatened patients. Multicenter studies involving a large population report that up to 20% of patients undergoing VIT have intolerance and systemic reactions to immunotherapy. Some of these side effects occur repeatedly and cannot be managed by standard treatment. A pre-treatment with the anti-IgE antibody omalizumab was useful in many cases. However, omalizumab is not approved for the indication anaphylaxis. Therefore, there is still no defined protocol for omalizumab pre-treatment, and the optimal duration, dosage as well as long-time benefits are still unclear. Case report: We present a 60-year-old female patient with mastocytosis who developed a severe anaphylactic reaction during initiation of bee VIT. Serum tryptase was elevated, and a KIT mutation D816V was subsequently confirmed. Component-resolved diagnostic tests revealed specific IgE antibodies to recombinant Api m 1 only. The patient was treated with 150 mg omalizumab, administered subcutaneously 5 weeks, 3 weeks, and 1 week prior to re-start of immunotherapy and for 2 months in parallel to VIT. Updosing was done by a 7-day rush schedule. During this period, no anaphylactic reaction developed, and the bee VIT was well tolerated with up to 200 µg bee venom. The patient is currently in the 3rd year of treatment and tolerates the treatment very well. Conclusion: Omalizumab may be used as a premedication in patients with mastocytosis who do not tolerate VIT. Although there is no consensus on the treatment protocol, treatment for 2 – 6 months is considered adequate. The long-term benefits of such treatment require further research.Correspondence to:
Prof. Dr. Uta Jappe, FG Klinische und Molekulare Allergologie, Forschungszentrum Borstel, Leibniz, Lungenzentrum, Parkallee 1 – 40, 23845 Borstel
Email: [email protected]
Original
Anaphylaxis in middle-aged patients
Wojciech Francuzik, Magdalena Kraft, Kathrin Scherer Hofmeier, Franziska Ruëff, Claudia Pföhler, Regina Treudler, Roland Lang, Thomas Hawranek, Nicola Wagner, und Margitta Worm
Volume 5 (2021) p. 133 - 139
Abstract
Allergologie select, Vol. 5/2021 (133-139)
Anaphylaxis in middle-aged patients
Wojciech Francuzik1, Magdalena Kraft1,2, Kathrin Scherer Hofmeier3, Franziska Ruëff4, Claudia Pföhler5, Regina Treudler6, Roland Lang7, Thomas Hawranek7, Nicola Wagner8, und Margitta Worm1
1Allergy and Immunology, Department of Dermatology, Venereology and Allergology, Charité – Universitätsmedizin Berlin, Berlin, 2Central Emergency Department, University Hospital Halle (Saale), Martin Luther University Halle-Wittenberg, Halle (Saale), Germany 3Allergology, Clinic for Dermatology, University Hospital Basel, Basel, Switzerland, 4Clinic and Polyclinic for Dermatology and Allergology, University Hospital Munich, Munich, 5Clinic for Dermatology, Venerology and Allergology, Saarland University Hospital and Medical Faculty of Saarland University, Homburg, 6Clinic and Polyclinic for Dermatology, Venerology and Allergology, Leipzig University Hospital, Leipzig, Germany, 7University Clinic for Dermatology and Allergology, Paracelsus Medical Private University Salzburg, Salzburg, Austria and 8Dermatology Clinic, Erlangen University Hospital, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
Age is one of the most important factors influencing the course of anaphylaxis: moreover, the frequency of elicitors of anaphylaxis is age-associated. We analyzed 8,465 anaphylactic episodes in adult patients in three age groups with a focus on patients in the middle-age group (35 – 65 years old). Insect venom was the most frequent trigger in this age group (51.2%) followed by drugs (22.8%) and food (17.3%). Severe reactions were observed in 40.1% of middle-aged patients and occurred more frequently in this age group than in patients below 35 years (27.6%) and less frequently than in patients over 65 years (55.6%). The symptoms and comorbidity profile also changed with age, most significantly regarding the increase in rates of concomitant cardiologic diseases and (severe) cardiovascular symptoms.Correspondence to:
Prof. Dr. med. Margitta Worm, Allergologie und Immunologie, Klinik für Dermatologie, Venerologie, und Allergologie, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin
Email: [email protected]
Guideline
Guideline for allergological diagnosis of drug hypersensitivity reactions
Knut Brockow, Gerda Wurpts, Axel Trautmann, Wolfgang Pfützner, Regina Treudler, Andreas J. Bircher, Randolf Brehler, Timo Buhl, Heinrich Dickel, Thomas Fuchs, Thilo Jakob, Julia Kurz, Burkhard Kreft, Lars Lange, Hans F. Merk, Maja Mockenhaupt, Norbert Mülleneisen, Hagen Ott, Johannes Ring, Franziska Ruëff, Bernhardt Sachs, Helmut Sitter, Bettina Wedi, Stefan Wöhrl, Margitta Worm, and Torsten Zuberbier
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Volume 7 (2023) p. 122 - 139
Abstract
Allergologie select, Vol. 7/2023 (122-139)
Guideline for allergological diagnosis of drug hypersensitivity reactions
Knut Brockow1, Gerda Wurpts2, Axel Trautmann3, Wolfgang Pfützner4, Regina Treudler5, Andreas J. Bircher6, Randolf Brehler7, Timo Buhl8, Heinrich Dickel9, Thomas Fuchs8, Thilo Jakob10, Julia Kurz4, Burkhard Kreft11, Lars Lange12, Hans F. Merk2, Maja Mockenhaupt13, Norbert Mülleneisen14, Hagen Ott15, Johannes Ring1, Franziska Ruëff16, Bernhardt Sachs2, Helmut Sitter17, Bettina Wedi18, Stefan Wöhrl19, Margitta Worm20, and Torsten Zuberbier20
1Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich, 2Department of Dermatology and Allergology, Germany, Aachen Comprehensive Allergy Center (ACAC), University Hospital of RWTH Aachen University, Aachen, 3Department of Dermatology and Allergology, Allergy Center Mainfranken, University Hospital Würzburg, Würzburg, 4Department of Dermatology and Allergology, University Hospital Giessen and Marburg, Marburg, 5Department of Dermatology, Venerology and Allergology, University of Leipzig, Leipzig, Germany, 6Facoltà di Scienze biomediche, Università della Svizzera italiana, Lugano, and Department of Dermatology and Allergology, University Hospital Basel, Switzerland, 7Department of Dermatology, Münster University Hospital, Münster, 8Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, 9Department of Dermatology, Venerology and Allergology, St. Josef Hospital, University Hospital of the Ruhr University Bochum, Bochum, 10Department of Dermatology and Allergology, University Hospital, Justus-Liebig University, Gießen, 11Department of Dermatology and Venereology, University Hospital Halle, Halle (Saale), 12Pediatric Clinic, Marienhospital Bonn, Bonn, 13Documentation Center for Severe Skin Reactions, Department of Dermatology and Venereology, University Medical Center Freiburg, Freiburg, 14Asthma Allergy Center Leverkusen, Leverkusen, 15Children’s and Youth Hospital Auf der Bult, Hanover, 16Department of Dermatology and Allergology, Allergy Center, Ludwig Maximilian University of Munich, 17Institute for Theoretical Surgery, Philipps University of Marburg, Marburg, 18Hanover Medical School, Department of Dermatology, Allergology and Venereology, Hanover, Germany, 19Floridsdorf Allergy Center (FAZ), Vienna, Austria, and 20Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Berlin, Germany
Correspondence to:
Prof. Dr. med. Knut Brockow, Department of Dermatology and Allergology at Biederstein, Faculty of Medicine, Technical University of Munich, Biedersteiner Straße 29, 80802 Munich, Germany
Email: [email protected]
Guideline
Diagnosis and treatment of Hymenoptera venom allergy
Franziska Ruëff, Andrea Bauer, Sven Becker, Randolf Brehler, Knut Brockow, Adam M. Chaker, Ulf Darsow, Jörg Fischer, Thomas Fuchs, Michael Gerstlauer, Sunhild Gernert, Eckard Hamelmann, Wolfram Hötzenecker, Ludger Klimek, Lars Lange, Hans Merk, Norbert K. Mülleneisen, Irena Neustädter, Wolfgang Pfützner, Wolfgang Sieber, Helmut Sitter, Christoph Skudlik, Regina Treudler, Bettina Wedi, Stefan Wöhrl, Margitta Worm and Thilo Jakob
Volume 7 (2023) p. 154 - 190
Abstract
Allergologie select, Vol. 7/2023 (154-190)
Diagnosis and treatment of Hymenoptera venom allergy
Franziska Ruëff1, Andrea Bauer2, Sven Becker3, Randolf Brehler4, Knut Brockow5, Adam M. Chaker6, Ulf Darsow5, Jörg Fischer7, Thomas Fuchs8, Michael Gerstlauer9, Sunhild Gernert10, Eckard Hamelmann11, Wolfram Hötzenecker12, Ludger Klimek13, Lars Lange10, Hans Merk14, Norbert K. Mülleneisen15, Irena Neustädter16, Wolfgang Pfützner17, Wolfgang Sieber18, Helmut Sitter19, Christoph Skudlik20, Regina Treudler21, Bettina Wedi22, Stefan Wöhrl23, Margitta Worm24 and Thilo Jakob25
1Department of Dermatology and Allergy, LMU University Hospital, Munich, 2Department of Dermatology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, 3Department of Otorhinolaryngology, Head and Neck Surgery, University of Tuebingen, Tübingen, 4Department of Dermatology, Münster University Hospital, Münster, 5Department of Dermatology and Allergology Biederstein, Faculty of Medicine, Technical University of Munich, Munich, 6Department of Otorhinolaryngology Klinikum rechts der Isar, Faculty of Medicine, Technical University of Munich, Munich, 7University Hospital for Dermatology and Allergology, Clinic Oldenburg, Oldenburg, 8Department of Dermatology, Venereology and Allergology, University Medical Center Göttingen, Göttingen, 9Clinic for Children and Adolescents, University Hospital Augsburg, Augsburg, 10Pediatric Clinic, Marienhospital Bonn, GFO Kliniken, Bonn, 11Children’s Center Bethel, University Hospital OWL, Bielefeld University, Bielefeld, Germany, 12Department of Dermatology, Kepler University Hospital, Medical Faculty of University Linz, Linz, Austria, 13Center for Rhinology and Allergology, Wiesbaden, 14Department of Dermatology and Allergology, University Hospital of RWTH Aachen University, Aachen, 15Center for Asthma and Allergy, Leverkusen, 16Cnopfsche Paediatric Clinic, Nuremberg, 17Department of Dermatology and Allergology, University Hospital Marburg, Philipps-Universität Marburg, Marburg, 18Hospital Wörth an der Donau, Wörth an der Donau, 19Institute for Theoretical Surgery, Philipps-University Marburg, Marburg, 20Institute for Interdisciplinary Dermatological Prevention and Rehabilitation (iDerm) at the University of Osnabrueck, Osnabrueck, and BG Clinic Hamburg, Hamburg, 21University Leipzig Medical Faculty, Leipzig, 22Comprehensive Allergy, Department of Dermatology and Allergy, Hannover Medical School, Hanover, Germany, 23Floridsdorf Allergy Center (FAZ), Vienna, Austria, 24Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Campus Charité Mitte, Berlin, and 25Department of Dermatology and Allergology, University Hospital Giessen, Justus Liebig University Gießen, Gießen, Germany
Hymenoptera venom (HV) is injected into the skin during a sting by Hymenoptera such as bees or wasps. Some components of HV are potential allergens and can cause large local and/or systemic allergic reactions (SAR) in sensitized individuals. During their lifetime, ~ 3% of the general population will develop SAR following a Hymenoptera sting. This guideline presents the diagnostic and therapeutic approach to SAR following Hymenoptera stings. Symptomatic therapy is usually required after a severe local reaction, but specific diagnosis or allergen immunotherapy (AIT) with HV (VIT) is not necessary. When taking a patient’s medical history after SAR, clinicians should discuss possible risk factors for more frequent stings and more severe anaphylactic reactions. The most important risk factors for more severe SAR are mast cell disease and, especially in children, uncontrolled asthma. Therefore, if the SAR extends beyond the skin (according to the Ring and Messmer classification: grade > I), the baseline serum tryptase concentration shall be measured and the skin shall be examined for possible mastocytosis. The medical history should also include questions specific to asthma symptoms. To demonstrate sensitization to HV, allergists shall determine concentrations of specific IgE antibodies (sIgE) to bee and/or vespid venoms, their constituents and other venoms as appropriate. If the results are negative less than 2 weeks after the sting, the tests shall be repeated (at least 4 – 6 weeks after the sting). If only sIgE to the total venom extracts have been determined, if there is double sensitization, or if the results are implausible, allergists shall determine sIgE to the different venom components. Skin testing may be omitted if in-vitro methods have provided a definitive diagnosis. If neither laboratory diagnosis nor skin testing has led to conclusive results, additional cellular testing can be performed. Therapy for HV allergy includes prophylaxis of reexposure, patient self treatment measures (including use of rescue medication) in the event of re-stings, and VIT. Following a grade I SAR and in the absence of other risk factors for repeated sting exposure or more severe anaphylaxis, it is not necessary to prescribe an adrenaline auto-injector (AAI) or to administer VIT. Under certain conditions, VIT can be administered even in the presence of previous grade I anaphylaxis, e.g., if there are additional risk factors or if quality of life would be reduced without VIT. Physicians should be aware of the contraindications to VIT, although they can be overridden in justified individual cases after weighing benefits and risks. The use of β-blockers and ACE inhibitors is not a contraindication to VIT. Patients should be informed about possible interactions. For VIT, the venom extract shall be used that, according to the patient’s history and the results of the allergy diagnostics, was the trigger of the disease. If, in the case of double sensitization and an unclear history regarding the trigger, it is not possible to determine the culprit venom even with additional diagnostic procedures, VIT shall be performed with both venom extracts. The standard maintenance dose of VIT is 100 µg HV. In adult patients with bee venom allergy and an increased risk of sting exposure or particularly severe anaphylaxis, a maintenance dose of 200 µg can be considered from the start of VIT. Administration of a non-sedating H1-blocking antihistamine can be considered to reduce side effects. The maintenance dose should be given at 4-weekly intervals during the first year and, following the manufacturer’s instructions, every 5 – 6 weeks from the second year, depending on the preparation used; if a depot preparation is used, the interval can be extended to 8 weeks from the third year onwards. If significant recurrent systemic reactions occur during VIT, clinicians shall identify and as possible eliminate co-factors that promote these reactions. If this is not possible or if there are no such co-factors, if prophylactic administration of an H1-blocking antihistamine is not effective, and if a higher dose of VIT has not led to tolerability of VIT, physicians should should consider additional treatment with an anti IgE antibody such as omalizumab as off lable use. For practical reasons, only a small number of patients are able to undergo sting challenge tests to check the success of the therapy, which requires in-hospital monitoring and emergency standby. To perform such a provocation test, patients must have tolerated VIT at the planned maintenance dose. In the event of treatment failure while on treatment with an ACE inhibitor, physicians should consider discontinuing the ACE inhibitor. In the absence of tolerance induction, physicians shall increase the maintenance dose (200 µg to a maximum of 400 µg in adults, maximum of 200 µg HV in children). If increasing the maintenance dose does not provide adequate protection and there are risk factors for a severe anaphylactic reaction, physicians should consider a co-medication based on an anti-IgE antibody (omalizumab; off-label use) during the insect flight season. In patients without specific risk factors, VIT can be discontinued after 3 – 5 years if maintenance therapy has been tolerated without recurrent anaphylactic events. Prolonged or permanent VIT can be considered in patients with mastocytosis, a history of cardiovascular or respiratory arrest due to Hymenoptera sting (severity grade IV), or other specific constellations associated with an increased individual risk of recurrent and/or severe SAR (e.g., hereditary α-tryptasemia). In cases of strongly increased, unavoidable insect exposure, adults may receive VIT until the end of intense contact. The prescription of an AAI can be omitted in patients with a history of SAR grade I and II when the maintenance dose of VIT has been reached and tolerated, provided that there are no additional risk factors. The same holds true once the VIT has been terminated after the regular treatment period. Patients with a history of SAR grade ≥ III reaction, or grade II reaction combined with additional factors that increase the risk of non response or repeated severe sting reactions, should carry an emergency kit, including an AAI, during VIT and after regular termination of the VIT.Correspondence to:
Prof. Dr. med. Franziska Ruëff, Klinik und Poliklinik für Dermatologie, und Allergologie, Klinikum der Universität München, Frauenlobstraße 9-11, 80337 Munich, Germany,
Email: [email protected]
Case Report
Diagnostic measures in patients with severe insect sting reactions and elevated baseline serum tryptase levels
Silvan Lange, Eva Oppel, Marius Winkler, and Franziska Ruëff
Volume 8 (2024) p. 299 - 303
Abstract
Allergologie select, Vol. 8/2024 (299-303)
Diagnostic measures in patients with severe insect sting reactions and elevated baseline serum tryptase levels
Silvan Lange, Eva Oppel, Marius Winkler, and Franziska Ruëff
Department of Dermatology and Allergy, LMU University Hospital, Munich, Germany
Mastocytosis or an elevated basal serum tryptase (bST) level are known risk factors for patients with insect venom allergy. We report on 3 patients with a history of severe anaphylactic insect sting reactions who underwent a detailed workup for insect venom allergy before starting venom immunotherapy. In addition to insect venom sensitization, an elevated concentration of bST (15.5, 20.8, and 23.2 μg/L) was found in all cases. There was no evidence of mastocytosis in the skin (MIS). Further testing revealed hereditary α-hypertryptasemia (HαT) in 2 patients and a D816V mutation by liquid biopsy in 1 patient, which is a minor diagnostic criterion for indolent systemic mastocytosis. Even without iliac crest puncture, causes of elevated bST can be narrowed down with minimally invasive diagnostic measures. As this has practical implications, patients with elevated bST should always undergo further work-up to determine the cause of this abnormal finding.Correspondence to:
Prof. Dr. med. Franziska Ruëff, Klinik und Poliklinik für Dermatologie und Allergologie, Allergiezentrum, LMU Klinikum, Frauenlobstr. 9 – 11, 80337 Munich, Germany
Email: [email protected]
Case Report
Long-term tolerance and efficacy of venom immunotherapy after an episode of Crohn’s disease and ankylosing spondylitis after up-dosing
Marius Winkler, Franziska Ruëff, Silvan Lange, Annett Walker, and Eva Oppel
Volume 8 (2024) p. 332 - 335
Abstract
Allergologie select, Vol. 8/2024 (332-335)
Long-term tolerance and efficacy of venom immunotherapy after an episode of Crohn’s disease and ankylosing spondylitis after up-dosing
Marius Winkler, Franziska Ruëff, Silvan Lange, Annett Walker, and Eva Oppel
Department of Dermatology and Allergy, LMU Munich, University Hospital, Munich, Germany
Hymenoptera stings can cause severe anaphylactic reactions in patients with an underlying Hymenoptera venom allergy (HVA). In such cases, venom immunotherapy (VIT) is a highly effective measure to prevent future anaphylaxis. The management of patients with a clear allergological indication for VIT and contraindications to VIT (e.g., autoimmune diseases) remains a clinical challenge. We report the case of a 54-year-old male gardener who experienced life-threatening anaphylaxis after being stung by wasps in the head and neck region. After confirmation of a Vespula venom allergy (VVA) by intradermal test and VV-specific serum IgE antibodies, VIT was started using a rush protocol. One month after reaching the maintenance dose, the patient experienced a worsening of his pre-existing Crohn’s disease and ankylosing spondylitis. VIT was stopped, and the autoimmune diseases were treated with systemic steroids and sulfasalazine. As the patient wished to remain in his profession, and in view of the previous severe anaphylaxis, we restarted VIT after the autoimmune diseases had resolved, using a slower up-dosing protocol. This approach was tolerated without side effects, and the patient tolerated a sting challenge and several field stings without anaphylactic symptoms.Correspondence to:
Marius Winkler, Klinik und Poliklinik für Dermatologie und Allergologie, Allergiezentrum, LMU Klinikum, Frauenlobstr. 9 – 11, 80337 München, Germany
Email: [email protected]
