Outcomes of Allergy to Insect Stings in Children, with and without Venom Immunotherapy

David B.K. Golden, M.D., Anne Kagey-Sobotka, Ph.D., Philip S. Norman, M.D., Robert G. Hamilton, Ph.D., and Lawrence M. Lichtenstein, M.D., Ph.D.

ABSTRACT

Background Children are thought to "outgrow" the allergy to insect stings, but there are no reports documenting the natural history of this reaction. We studied the outcome of allergic reactions to insect stings in childhood 10 to 20 years afterward in patients who had not received venom immunotherapy and in those who had been treated.

Methods Between 1978 and 1985, we diagnosed allergic reaction to insect stings in 1033 children, of whom 356 received venom immunotherapy. We conducted a survey of these patients by telephone and mail between January 1997 and January 2000, to determine the outcome of stings that occurred in the period from 1987 through 1999.

Results Of the 1033 patients, 512 patients (50 percent) responded, with a mean follow-up period of 18 years, a mean duration of venom immunotherapy of 3.5 years in treated patients, and an incidence of stings of 43 percent. Systemic reactions occurred less frequently in patients who had received venom immunotherapy (2 of 64 patients, or 3 percent) than in untreated patients (19 of 111 patients, or 17 percent; P=0.007). Patients with a history of moderate-to-severe reactions had a higher rate of reaction if they had not been treated (7 of 22 patients, or 32 percent) than if they had received venom immunotherapy (2 of 43 patients, or 5 percent; P=0.007). In patients who had been treated and who had a history of mild (cutaneous) systemic reaction (i.e., one with only cutaneous manifestations), none of the 21 subjects who received stings had a systemic reaction.

Conclusions A clinically important number of children do not outgrow allergic reactions to insect stings. Venom immunotherapy in children leads to a significantly lower risk of systemic reaction to stings even 10 to 20 years after treatment is stopped, and this prolonged benefit is greater than the benefit seen in adults.

Outbreak of Adverse Reactions Associated with Contaminated Heparin

David B. Blossom, M.D., Alexander J. Kallen, M.D., M.P.H., Priti R. Patel, M.D., M.P.H., Alexis Elward, M.D., M.P.H., Luke Robinson, B.S., Ganpan Gao, Ph.D., Robert Langer, Sc.D., Kiran M. Perkins, M.D., Jennifer L. Jaeger, M.D., Katie M. Kurkjian, D.V.M., M.P.H., Marilyn Jones, R.N., M.P.H., Sarah F. Schillie, M.D., M.P.H., Nadine Shehab, Pharm.D., Daniel Ketterer, M.D., Ganesh Venkataraman, Ph.D., Takashi Kei Kishimoto, Ph.D., Zachary Shriver, Ph.D., Ann W. McMahon, M.D., K. Frank Austen, M.D., Steven Kozlowski, M.D., Arjun Srinivasan, M.D., George Turabelidze, M.D., Ph.D., Carolyn V. Gould, M.D., Matthew J. Arduino, Dr.P.H., and Ram Sasisekharan, Ph.D.

ABSTRACT

Background In January 2008, the Centers for Disease Control and Prevention began a nationwide investigation of severe adverse reactions that were first detected in a single hemodialysis facility. Preliminary findings suggested that heparin was a possible cause of the reactions.

Methods Information on clinical manifestations and on exposure was collected for patients who had signs and symptoms that were consistent with an allergic-type reaction after November 1, 2007. Twenty-one dialysis facilities that reported reactions and 23 facilities that reported no reactions were included in a case–control study to identify facility-level risk factors. Unopened heparin vials from facilities that reported reactions were tested for contaminants.

Results A total of 152 adverse reactions associated with heparin were identified in 113 patients from 13 states from November 19, 2007, through January 31, 2008. The use of heparin manufactured by Baxter Healthcare was the factor most strongly associated with reactions (present in 100.0% of case facilities vs. 4.3% of control facilities, P<0.001).> by Baxter from facilities that reported reactions contained a contaminant identified as oversulfated chondroitin sulfate (OSCS). Adverse reactions to the OSCS-contaminated heparin were often characterized by hypotension, nausea, and shortness of breath occurring within 30 minutes after administration. Of 130 reactions for which information on the heparin lot was available, 128 (98.5%) occurred in a facility that had OSCS-contaminated heparin on the premises. Of 54 reactions for which the lot number of administered heparin was known, 52 (96.3%) occurred after the administration of OSCS-contaminated heparin.

Conclusions Heparin contaminated with OSCS was epidemiologically linked to adverse reactions in this nationwide outbreak. The reported clinical features of many of the cases further support the conclusion that contamination of heparin with OSCS was the cause of the outbreak.

Allergic Reaction Causes

Almost anything can trigger an allergic reaction.

 
The body's immune system has a patrol of white blood cells, which produce antibodies. 

 
When the body is exposed to an antigen, a complex set of reactions begins. 

 
The white blood cells produce an antibody specific to that antigen. This is called "sensitization." 

 
The job of the antibodies is to detect and destroy substances that cause disease and sickness. In allergic reactions, the antibody is called immunoglobulin E, or IgE.

 
This antibody promotes production and release of chemicals and hormones called "mediators." 

 
Histamine is one well-known mediator. 

 
Mediators have effects on local tissue and organs in addition to activating more white blood cell defenders. It is these effects that cause the symptoms of the reaction. 

 
If the release of the mediators is sudden or extensive, the allergic reaction may also be sudden and severe.

 
Your allergic reactions are unique to you. For example, your body may have learned to be allergic to poison ivy from repeated exposure.

 
Most people are aware of their particular allergy triggers and reactions.

 
Certain foods, vaccines and medications, latex rubber, aspirin, shellfish, dust, pollen, mold, animal dander, and poison ivy are famous allergens. 

 
Bee stings, fire ant stings, penicillin, and peanuts are known for causing dramatic reactions that can be serious and involve the whole body. 

 
Minor injuries, hot or cold temperatures, exercise, or even emotions may be triggers. 

 
Often, the specific allergen cannot be identified unless you have had a similar reaction in the past.

 
Allergies and the tendency to have allergic reactions run in some families. You may have allergies even if they do not run in your family.

 
Many people who have one trigger tend to have other triggers as well.

 
People with certain medical conditions are more likely to have allergic reactions. 

 
Severe allergic reaction in the past 

 
Asthma

 
Lung conditions that affect breathing, such as chronic obstructive pulmonary disease (COPD) 

 
Nasal polyps 

 
Frequent infections of the nasal sinuses, ears, or respiratory tract 

 
Sensitive skin

What Are Allergies?

Allergies are an abnormal response of the immune system. People who have allergies have an immune system that reacts to a usually harmless substance in the environment. This substance (pollen, mold, animal dander, etc.) is called an allergen.

Allergies are a very common problem, affecting at least 2 out of every 10 Americans.
What Happens During an Allergic Reaction?

When a person is exposed to an allergen, a series of events takes place:
The body starts to produce a specific type of antibody, called IgE, to bind the allergen.
The antibodies attach to a form of blood cell called a mast cell. Mast cells can be found in the airways, in the GI tract, and elsewhere. The presence of mast cells in the airways and GI tract makes these areas more susceptible to allergen exposure.
The allergens bind to the IgE, which is attached to the mast cell. This triggers a reaction that allows the mast cells to release a variety of chemicals including histamine, which causes most of the symptoms of an allergy, including itchiness or runny nose.

If the allergen is in the air, the allergic reaction will likely occur in the eyes, nose and lungs. If the allergen is ingested, the allergic reaction often occurs in the mouth, stomach, and intestines. Sometimes enough chemicals are released from the mast cells to cause a reaction throughout the body, such as hives, decreased blood pressure, shock, or loss of consciousness.
What Are the Symptoms of Allergies?

Allergy symptoms can be categorized as mild, moderate, or severe (anaphylactic).
Mild reactions include those symptoms that affect a specific area of the body such as a rash, itchy, watery eyes, and some congestion. Mild reactions do not spread to other parts of the body.
Moderate reactions include symptoms that spread to other parts of the body. These may include itchiness or difficulty breathing.
A severe reaction, called anaphylaxis, is a rare, life-threatening emergency in which the response to the allergen is intense and affects the whole body. It may begin with the sudden onset of itching of the eyes or face and progress within minutes to more serious symptoms, including abdominal pain, cramps, vomiting, and diarrhea, as well as varying degrees of swellings that can make breathing and swallowing difficult. Mental confusion or dizziness may also be symptoms, since anaphylaxis causes a quick drop in blood pressure.
Does Everyone Have Allergies?

No. Most allergies are inherited, which means they are passed on to children by their parents. People inherit a tendency to be allergic, although not to any specific allergen. When one parent is allergic, their child has a 50% chance of having allergies. That risk jumps to 75% if both parents have allergies.