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Insect anaphylaxis: addressing clinical challenges

Tracy, James M.; Lewis, Elena J.; Demain, Jeffrey G.

Current Opinion in Allergy & Clinical Immunology: August 2011 - Volume 11 - Issue 4 - p 332–336
doi: 10.1097/ACI.0b013e32834877ab
Anaphylaxis and insect allergy: Edited by Theodore Freeman and Ralf G. Heine

Purpose of review: Few allergic reactions are as potentially life-threatening, or frightening to the patient, as anaphylaxis. Food, medications, and insect stings are the three most common triggers of anaphylaxis, but insect allergy provides the best opportunity to understand the biology of anaphylaxis. If the physician can establish a diagnosis of insect allergy, treatment with nearly 98% effectiveness can be initiated. However, sometimes patients have a compelling history of insect sting anaphylaxis, but negative skin and blood tests. This situation presents us with a fascinating opportunity to understand the biology of insect anaphylaxis.

Recent findings: Recent and ongoing work shows that occult mast cell disease may be critical in insect anaphylaxis. Mastocytosis, serum tryptase and basophil biology are key elements; genetic markers may potentially help us diagnose at-risk individuals and determine proper treatment. Understanding basophil activation may play an additional role both in diagnosis and knowing when therapy might be terminated.

Summary: Mast cell disease, serum tryptase and basophil biology are providing an opportunity to better understand and manage insect allergy. This evolving understanding should improve long-term management of insect anaphylaxis and help us to better understand the clinical dilemma of appropriate management of the history-positive patient in which testing is unable to detect venom-specific IgE. Furthermore, omalizumab's immunomodulatory effects may play a role in difficult-to-treat insect allergy and mastocytosis. Finally, unrelated to these, but still important as an ongoing risk factor, is the continued underutilization of epinephrine for both acute and long-term management of insect anaphylaxis.

Division of Allergy and Immunology and Allergy, Asthma & Immunology Associates, Omaha, Nebraska, USA

Correspondence to James M. Tracy, D.O., Creighton University School of Medicine, Allergy, Asthma & Immunology Associates, P.C. 2808 South 80th Ave, Suite 210, Omaha, NE 68124, USATel: +1 402 391 1800; e-mail: jmtracy@cox.net

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