Stinging insect allergy: Natural history and modification with venom immunotherapy

The natural history of stinging insect allergy and its modification by venom immunotherapy was investigated by follow-up observations of patients with histories of venom anaphylaxis and detectable venom-specific IgE. The patients were divided into three categories: (1) receiving venom immunotherapy, (2) declined venom immunotherapy, and (3) terminated venom immunotherapy. One hundred twenty-seven patients were evaluated after 6 mo to 9 yr of venom immunotherapy. Most received top venom doses of 50 μg of yellow jacket and/or honeybee venoms every 4 wk. There were 87 restings in 48 patients resulting in two systemic reactions, only one of which could be considered a treatment failure (1%). Fifty-six patients never received venom immunotherapy. In this group there were 40 restings in 28 patients with 14 systemic reactions (35%). In 88 patients who stopped venom immunotherapy, 61 restings in 41 patients led to 11 systemic reactions (17%). Patients with cardiovascular/or respiratory symptoms with initial sting anaphylaxis were at risk for subsequent reactions. With one exception, patients with hives and edema only as the initial reaction either had a similar or no reaction when they were restung. These results confirm the efficacy of venom immunotherapy but also suggest that there are factors other than the presence of venom-specific IgE modulating the occurrence of clinical anaphylaxis.     

Comparison of biochemical and immunologic properties of venoms from four hornet species

Venoms of two American hornets, Vespula maculata (bald-faced hornet) and Vespula arenaria (yellow hornet), and two Old World hornets, Vespa crabro and Vespa orientalis, were investigated for biochemical and immunologic properties. They were similar with regard to enzymatic activities (phospholipase A, phospholipase B, and hyaluronidase) and molecular composition. Analysis of radioallergosorbent test (RAST) results obtained from 30 vespid-sensitive patients suggests extensive cross-reactivity between the venoms of V. arenaria, V. maculata, and V. crabro, but the venom of V. orientalis seems to lack at least one important allergen. Rabbit antisera to each of the four venoms contain precipitating antibodies to all four venoms. Strong cross-reactivity was found between the venoms of V. maculata, V. arenaria, and V. crabro and between V. crabro and V. orientalis. V. orientalis venom cross-reacts weakly with the venoms of both V. maculata and V. arenaria. It is concluded therefore that diagnosis and immunotherapy with commercially available venoms of V. maculata and V. arenaria should be adequate for most patients sensitive to V. maculata, V. arenaria, or V. crabro but probably not for a significant proportion of those individuals primarily sensitive to V. orientalis.     

Comparison of vespid venoms collected by electrostimulation and by venom sac extraction

Venoms of three vespid species, yellow jacket, bald-faced hornet, and yellow hornet, obtained by either electrostimulation or venom sac extraction were compared with regard to their enzymatic activity, antigenicity, and allergenicity. Phospholipase A, phospholipase B, and hyaluronidase enzymatic activities were present in all six preparations. The activity of venom sac extracts lay in the range found in different batches of venoms obtained by electrostimulation for each species. Analysis of sera from vespid-sensitive patients in the radioallergosorbent test (RAST) with discs coupled with either venom sac extracts or venoms obtained by electrostimulation showed a good correlation of the results within all three species (r = 0.95). In RAST inhibition the potency of venom sac extracts and venom obtained by electrostimulation was similar for each species. Analysis of rabbit antisera to the six preparations revealed similar patterns in immunoelectrophoresis and identity reactions between the major antigens within each species. Tissue protein contamination was detected in all venom sac extracts but not in venoms obtained by electrostimulation.     

Comparison of the venom immunogenicity of various species of yellow jackets (genus Vespula)

Venoms from various yellow jacket species were examined by two-dimensional thin-layer chromatography (TDTLC), double-diffusion gel precipitation (DDGP) using rabbit antisera, and the radioallergosorbent test (RAST). Comparison of representative venoms by the TDTLC showed that the venoms of V. vulgaris and V. maculifrons have a larger number of Ninhydrin (triketohydrindene hydrate)-positive substances than the venom of V. squamosa. The results of the DDGP confirmed the differences; venoms of V. vulgaris, V. maculifrons, V. flavopilosa, and V. germanica have one or more major components with immunogenic identity. The venom of V. squamosa has a species-specific major component and some minor components immunologically identical to the other venoms examined. Sera from 21 patients with a history of anaphylaxis following yellow jacket stings were examined by the RAST. Using the venoms of V. maculifrons, V. vulgaris, V. flavopilosa, and V. germanica as coupling antigens, most sera reacted similarly. The sera did not react with V. squamosa. These results suggest that the major component in venom obtained from the four yellow jacket species has immunogenic identity. Venom of V. squamosa differs from the remaining venoms. As a practical corollary, with the exception of venom from V. squamosa, common sensitivity appears to exist among the yellow jacket venoms examined.     

Venom skin tests in insect-allergic and insect-nonallergic populations

Intradermal skin tests with varying concentrations of honeybee, yellow jacket, white-faced hornet, yellow hornet, and Polistes venoms were done on 85 patients with histories of insect-sting anaphylaxis and on 56 insect-nonallergic subjects. Positive skin tests (wheal greater than or equal to 5 to 10 mm and flare greater than or equal to 11 to 20 mm) were present in 67 insect-allergic patients at venom concentrations ranging from 0.001 microgram/ml to 0.1 microgram/ml. Seven additional allergic patients had positive skin tests with the 1.0 microgram/ml venom concentration. Twenty-six nonallergic subjects had positive skin tests at the venom concentration of 1.0 microgram/ml, and two patients had positive skin tests at the lower venom concentrations (0.001 to 0.1 microgram/ml). These results confirm venom skin tests as a highly sensitive method of detecting venom-specific IgE in the evaluation of patients with stinging-insect hypersensitivity. Since a large percentage of insect-nonallergic subjects reacted to the 1.0 microgram/ml concentration, clinical judgment and further in vitro testing should be considered in the evaluation of patients who react only at this venom concentration.     

Sensitization to nonvenom contaminants in a venom preparation.

An individual is described who appeared to be sensitive to nonvenom contaminants in a venom preparation. His IgE antibodies, measured by the immediate direct skin test and the radioallergosorbent test (RAST), reacted with a yellow jacket venom preparation obtained by "washing" of venom sacs. With yellow jacket venom obtained by electriral stimulation, there was a skin test reaction of equivocal significance and no serum antibodies were detected by the RAST. Moderate reactions were also found with yellow jacket body extracts. In contrast, sera obtained from patients with yellow jacket sting anaphylaxis showed strong reactions with the electrically stimulated venom preparation and only a few reacted with the body extract. In additional studies, the patient's serum reacted with yellow jacket extracts devoid of venom and a variety of hornet and wasp extracts. Analyses of the two yellow jacket venoms by gel diffusion using rabbit antisera showed the presence of body proteins in the venom obtained by venom sac "washing." Subsequent history revealed the presence of insect nests in the roof of the patient's bedroom, perhaps the source of inhalant exposure and sensitivity. This case history demonstrates the need for venom extracts that do not contain potentially sensitizing extraneous material.     

Clinical and immunologic studies of patients with large local reactions following insect stings

During the summer of 1978, 22 patients who had large local reactions following insect stings were evaluated for the development of potential systemic sensitivity. Approximately half the patients had venom IgE antibodies, detected by either the immediate skin test or radioallergosorbent test (RAST). A control group of 26 patients experiencing normal sting reactions had only a 15% incidence of venom-specific IgE. No correlations could be found between the presence of venom-specific IgE and age, sex, sting location, atopic history, or prior stings. IgE antibodies were found in 13 of 17 patients who had experienced local reactions lasting more than 48 hr. Serum venom-specific IgG was detected in only three of 19 patients. These results suggest that following large local reactions from insect stings patients must be individually assessed for the presence of venom-specific IgE and consideration for specific immunotherapy.     

Anaphylactic reaction to penicillin (or penicillin-like substance) in a soft drink

An acute anaphylactic reaction occurred in a patient known to be highly sensitive to penicillin following ingestion of the soft drink Wink. Bacteriologic studies showed the presence of penicillin or a penicillin-like substance in the Wink, suggesting it as the cause of the anaphylaxis. The source of this contaminant could not be identified.     

Immunologic and biochemical evaluation of the potency of whole insect body extracts.

Recent studies have indicated that currently available whole body extracts have little potency and are ineffective for diagnosis and treatment of stinging insect allergy. Pure venom is a potent effective allergen but is difficult to obtain in sufficient quantities from all Hymenoptera species. In these studies, an attempt was made to prepare a potent whole body extract. Whole bee body extracts were prepared with different extraction periods and at cold and room temperatures. Potency was examined biochemically by measurements of phospholipase A (PLA) activity and immunologically by PLA and bee venom radioallergosorbent test (RAST) inhibition experiments and gel diffusion studies with the use of rabbit antisera. All extracts prepared in the laboratory had some potency, indicating that it is possible to make a whole body extract containing small quantities of PLA or bee venom. However, the potency of these extracts was minimal as compared with bee venom. Three commercial extracts were almost devoid of detectable immunologic activity. While further attempts may be made to prepare a potent whole body insect extract, these results suggest that it is necessary to obtain venom in relatively pure form for the diagnosis and treatment of stinging insect allergy.     

Effect of ragweed hyperimmune human gamma globulin on in vivo and in vitro parameters of ragweed sensitivity.

The effect of ragweed hyperimmune human gamma globulin upon in vitro and in vivo parameters of ragweed sensitivity was examined. In a double-blind study, 40 ragweed sensitive patients were divided into 2 groups and received either ragweed hyperimmune human gamma globulin (treated) or normal pooled globulin (control). Parameters of ragweed sensitivity studied before and following injections of the gamma globulin included skin test and nasal provocation end point titration, specific IgE antibody as measured by the RAST, leukocyte histamine release, total serum ragweed antibody level, and total serum IgE. Changes in measured parameters varied in both groups of patients. In the "treated" patient group, 1 wk later nasal sensitivity decreased significantly, and there was a trend toward decreased histamine release from leukocytes. No discernable effect was noted upon the other parameters. Thus, with the dosage used, the parenterally administered hyperimmune gamma globulin did not influence most measurements of ragweed hypersensitivity. The concept of this therapeutic approach might warrant further investigation.     

Studies of the antigenicity and allergenicity of phospholipase A2 of bee venom.

The antigenic and allergenic properties of phospholipase A2 (PLA2) and whole bee venom were compared by measuring the IgG and IgE antibody responses in animals and man. Precipitating antibodies raised in rabbits and reaginic and other antibodies raised in mice reacted about equally with both bee venom and PLA. The majority of human sera containing bee venom-specific IgE also contained PLA-specific IgE, although in somewhat lower titers. Similarly, most human sera with significant amounts of total antibodies reacting with bee venom also had antibodies reacting with PLA. Histamine and SRS-a release from leukocytes of sensitive patients followed challenge with whole bee venom and PLA in the majority of instances. However, mediator release from several patients' cells was obtained with bee venom only. These studies suggest that although PLA is a major allergen and antigen in bee venom, significant exceptions in patients' reactivity may limit its potential diagnostic and therapeutic usefulness.     

Unusual reactions following insect stings. Clinical features and immunologic analysis.

Fifteen patients were studied who had unusual reactions following insect stings. These included serum sickness, neurologic disease, renal disease, and delayed hypersensitivity-type reactions. The clinical features are briefly outlined. Measurements were made of serum venom-specific IgE and IgG antibodies. These antibodies were present in some patients and in these instances suggested an immunologic pathogenesis for the reactions. Alternative etiologies for the unusual reactions are also discussed.     

Glycogenolysis and control of anaphylactic histamine release by cyclic adenosine monophosphate--related agents.

The relationship of glycogen and glucose to anaphylactic histamine release from chopped sensitized guinea pig lung in vitro was studied. A parallelism was observed between the total amount of glycogen in the sensitized lung and the total amount of histamine released from the lung by antigen-antibody reactions. Removal of glucose from the medium for tissue suspension resulted in reduction in histamine release. Depletion of glycogen and/or glucose from the system was associated with (1) abolition of the inhibition of histamine release by isoproterenol and high concentrations of dibutyryl cyclic adenosine monophosphate (AMP) and (2) increase in the rate of enhancement of histamine release by lower concentrations of dibutyryl cyclic AMP. The results indicate that (1) glycogen may be one of the ultimate energy sources for anaphylactic histamine release, and (2) the presence of adequate amounts of glycogen and/or glucose in the sensitized tissue is necessary for the normal beta adrenergic effects on the histamine release in vitro from sensitized lung fragments.     

Clinical application of measurements of serum levels of bee venom-specific IgE and IgG

Bee venom-specific IgE and IgG antibodies were measured in the serum of beekeepers, bee-allergic persons, and normal persons infrequently stung without adverse effects. Beekeepers, who are stung frequently and relatively “immune” to bee stings, are characterized by high serum levels of IgG- and low serum levels of IgE-specific antibodies. Bee-allergic individuals have high titers of bee venom-specific IgE and generally low titers of bee venom-specific IgG. Following a bee sting, allergic individuals develop a rising titer of IgE antibodies, accompanied occasionally by a rise in IgG antibodies. Therapy with whole bee body extracts fail to effect IgE or IgG antibody titers. During the course of venom immunotherapy IgG-specific antibodies are stimulated and IgE-specific antibodies continue to decline. These observations suggest that: (1) bee sting allergy is a function of bee venom-specific IgE; (2) bee sting immunity is a function of bee venom-specific IgG; and (3) bee venom is an appropriate therapeutic antigen.     

Glycogenolysis and control of anaphylactic histamine release by cyclic adenosine monophosphate-related agents. II. Modification of histamine release by glycogenolytic metabolites.

D-glucose-6-phosphate (less than or equal to 5 x 10(-3) M), pyruvate, lactate (less than or equal to 1 X 10(-2) M), and dibutyryl cyclic AMP (less than 5 X 10(-3) M) were capable of inhibiting anapylactic histamine release in vitro from chopped guinea pig lung. In lower concentrations, pyruvic acid and lactate, as well as dibutyryl cyclic AMP, enhanced the release. Significant synergism was observed betweenpyruvate (5 X 10(-3) M) and isoproterenol (1 X 10(-8) M) in the inhibition of histamine release. The inhibitory actions of isoproterenol, glucose-6-phosphate, and pyruvate were influenced by calcium ion concentration. However, beta blockade, which diminished the isoproterenol effect, was without efect on pyruvate (1 X 10(-2) M) to the release system. Glucose-6-phosphate and isoproterenol did not have this effect. The results, together with a prevouus study, suggest that glycogenolysis may possess a role in the anaphylactic istamine release in vitro from sensitized lung fragments...     

Inhibition of antigen-induced histamine release by ouabain.

The effect of ouabain, a specific sodium-potassium dependent adenosine triphosphatase (Na+-K+-ATPase) inhibitor, on antigen-induced histamine release was studied using guinea pig lung fragments sensitized in vitro with rabbit antibodies against bovine serum albumin. Histamine was assayed spectrofluorometrically. When sensitized tissue had been preincubated with ouabain (less than or equal to 1.0 x 10(-4) M) for 10 min prior to antigenic challenge, release of histamine was significantly inhibited (maximum 54%, p less than 0.001, N=9, paired t test). The most significant inhibition was obtained near the optimal concentration of antigen. The inhibition was dependent on the length of preincubation (less than or equal to 20 min), and was partially reversible upon washing the tissue removing the ouabain. Ouabain did not seem to prolong the duration of the histamine release process. Increase in potassium ion (less than or equal to 1.1 x 10(-2)M) inhibited the histamine release and had additive effects to ouabain action. Dibutyryl cyclic AMP (less than or equal to 5 x 10(-3) M), which could enhance the release, strongly antagonized the inhibition. Glucose removal from the medium did not abolish the ouabain effect. The results seem to indicate that immunologic release of histamine is under the influence of the membrane Na+-K+-ATPase activity.