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Stings & Things


By Mark Oswell

WRNMMC PA Specialist

Walter Reed National Military Medical Center recently hosted Dr. B.K. Golden, allergist, to address “Stings & Things.”
A world expert on anaphylaxis, insect allergies and venom immunotherapy, Golden drew from his 27 years of medical experience to detail the diagnosis and treating of anaphylaxis.
According to the Department of Health and Human Services, an estimated 10.1 million people in the United States visited emergency rooms for non-canine bite and sting injuries between 2001 to 2010.
Golden provided the Walter Reed Bethesda allergists, pediatricians and internal medicine primary care providers with clinical and research information pertaining to measures to avoid getting stung, risks for severity and dosing for venom immunotherapy, and concluded his presentation by taking the participants through several case studies.
Although some people seem to be immune to stings, others have anaphylaxis, or a severe reaction to the toxins that these insects inject.
“An allergic reaction can involve symptoms such as hives, shortness of breath, wheezing, swelling, flushing, vomiting, diarrhea and most concerning, loss of consciousness due to low blood pressure,” explained Army Col. (Dr.) Maureen Petersen, an allergist at WRB and the National Capital Consortium Allergy/Immunology Fellowship director.
Petersen explained that when an insect stings a person, they inject proteins. Some people have immune systems which can over-react to these proteins and create IgE specific to the stinging insect proteins. IgE is an allergy antibody that attaches to an allergy cell called a mast cell. These mast cells contain histamine. The mast cell with specific IgE then waits until the next time the person is exposed to whatever the IgE is specific to (in this case, a stinging insect). If a person is stung, the specific IgE recognizes the protein of the insect venom and sends a signal to the mast cell to explode and release histamine. The release of histamine causes an allergic reaction. 
According to the Centers for Disease, Control and Prevention (CDC), an estimated 90 to 100 die as a result of allergic reactions to insect stings each year people in the United States.
Impact on Readiness
An allergy to a stinging insect can impact medical readiness.  New potential recruits may not be eligible to enter the military without a waiver if they have not completed five years of venom allergy shots. Some services require a medical board for evaluation of being "fit for duty" if a patient has an allergic reaction to a stinging insect. A stinging insect allergy can affect the patient's job in the military particularly if the patient is an aviator.
Aviators are unique in that they operate in a closed environment, the cockpit of an aircraft. Since flying insects are able to get into an aircraft, it would be dangerous for a venom-allergic aviator to be trapped in an aircraft with a stinging insect, Petersen elaborated. This would be a disqualifying condition according to the flight medicine instructions unless the pilot has had a completed venom immunotherapy, according to the Army allergist.
If someone has been stung and is having local swelling at the sting site, the most common treatment is to ice the area and self-treatment with ibuprofen to reduce the swelling. However, if the person starts to have an allergic reaction involving any of the previously mentioned symptoms, they should seek emergency medical care and follow-up with an allergist, explained Petersen.
A patient with anaphylaxis is treated with injectable epinephrine, or potentially an antihistamine and oral steroid. A patient with a history of anaphylaxis to a stinging insect should be prescribed an epinephrine auto-injector to have on hand for any future reactions.
WRB’s Bee Day
“In the allergy clinic at WRNMMC, we have a monthly ‘Bee Day’ during which we schedule patients who need to be evaluated for a stinging insect allergy,” explained Petersen. “This is the day that we have skin testing reagents available to test venom allergic patients. The skin testing extracts for stinging insects used for testing requires multiple dilutions which are only stable for a short period of time.” WRB Allergy/Immunology service discusses the treatment plans of all stinging insect allergic patients to combat future anaphylaxis. 
“In my opinion, no complete medical history is complete without asking the question, ‘Have you ever had a severe reaction to an insect sting?’ If you ask that question, you’ll get a positive response in close to 10-percent of the time,” detailed Golden.