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Introduction: In the American continent, accidents caused by honeybees are a public health problem due to the high incidence and severity of the cases. Despite its medical importance, there are few epidemiological studies on this topic in Brazil, especially referring to the Northeastern states. The present study aims to describe the epidemiological features of honeybee envenomation cases in the state of the Rio Grande do Norte, Northeastern Brazil, from 2007 to 2014., Methods: Data were collected from the Notifiable Diseases Information System database of the Health Department of Rio Grande do Norte., Results: We analyzed a total of 2,168 cases. Cases occurred in all months of the years studied, reaching higher frequencies from June to October. Most incidents happened in urban areas and involved men, with victims aged between 20 and 39 years. Victims were mainly stung on the head and hand, and they received medical care predominantly within 3 hours after the injury. Local manifestations were more frequent than systemic ones. Clinically, most cases were mild and progressed to cure., Conclusion: The high number of honeybee sting cases shows that Rio Grande do Norte may be an important risk area for such injury.

Introduction: We evaluated the epidemiological and clinical profile of reported cases of bee sting incidents in Santa Catarina, Brazil., Methods: This retrospective cohort study included all reported cases of bee sting incidents among the population of Santa Catarina from 2007 to 2017., Results: In total, 8,912 cases were reported, corresponding to an overall rate of 12.3/100,000 population. The mean age was 29,8 years with 60.2% men. The lethality rate was 0.2%., Conclusions: Santa Catarina has a high incidence rate of bee stings, which is higher than the national average. The data presented in this study may be underestimated.

We describe three clinical cases of Surinamese children with rhabdomyolysis with diverse clinical presentation and course. The first patient had rhabdomyolysis because of toxins caused by multiple beestings and developed acute kidney injury. The other two patients had rhabdomyolysis following acute infection with chikungunya and influenza A/H1N1 virus. These cases emphasize that the diverse etiology of rhabdomyolysis should be considered in children in tropical settings., (© The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Envenoming syndrome is a systemic toxic reaction to the inoculation of large volume of insect venom, typically after a swarm attack from bees. Africanized honey bees are notorious for their aggressive nature, and human deaths resulting from Africanized honey bee attacks are consistently reported. Whereas anaphylaxis is the most common lethal mechanism of injury, delayed deaths can also occur as a consequence of severe venom toxicity with resultant end organ damage. Acute renal failure complicating massive envenomation is a rare but potentially fatal outcome after Africanized honey bee attack and may be heralded by laboratory evidence of rhabdomyolysis.

Introduction: Hymenoptera venom allergy is associated with significant morbidity and deterioration in health-related quality of life, and risk of fatal systemic reactions. Although venom immunotherapy is safe and the only effective treatment in allergic individuals, some patients prefer not to pursue this treatment. Since 2011, when the 50% reimbursement was stopped, patients must fully support the cost of immunotherapy. This study aimed to ascertain the reasons why patients decline immunotherapy., Material and Methods: A medical records review of all patients proposed to receive venom immunotherapy at an Allergy and Clinical Immunology Department in Porto, Portugal, between 2006 and 2015, followed by a phone interview to patients refusing treatment., Results: A total of 83 subjects were enrolled, with a mean (± SD) age of 44.4 (14.7) years and 55 (66%) males; 27 refused venom immunotherapy between 2006 and 2015. Nineteen were interviewed and 14 of those stated price as the main reason for declining treatment. The only identified risk factor associated with immunotherapy refusal was being proposed after 2011 (OR: 3.29; 95% CI: 1.12 - 9.68; p = 0.03)., Discussion: The number of patients refusing venom immunotherapy doubled since reimbursement was withdrawn. Price was identified as the major obstacle to treatment completion. Immunotherapy proposal after reimbursement was stopped was associated with a 3-fold increase in the risk of refusing treatment., Conclusion: These findings show how economic decisions may have a detrimental effect on patient care, as immunotherapy refusal left them exposed to an avoidable life-threatening risk.

Bee stings can cause severe reactions and have caused many victims in the last years. Allergic reactions can be triggered by a single sting and the greater the number of stings, the worse the prognosis. The poisoning effects can be systemic and can eventually cause death. The poison components are melitin, apamin, peptide 401, phospholipase A2, hyaluronidase, histamine, dopamine, and norepinephrine, with melitin being the main lethal component. Acute kidney injury (AKI) can be observed in patients suffering from bee stings and this is due to multiple factors, such as intravascular hemolysis, rhabdomyolysis, hypotension and direct toxicity of the venom components to the renal tubules. Arterial hypotension plays an important role in this type of AKI, leading to ischemic renal lesion. The most commonly identified biopsy finding in these cases is acute tubular necrosis, which can occur due to both, ischemic injury and the nephrotoxicity of venom components. Hemolysis and rhabdomyolysis reported in many cases in the literature, were demonstrated by elevated serum levels of indirect bilirubin and creatine kinase. The severity of AKI seems to be associated with the number of stings, since creatinine levels were higher, in most cases, when there were more than 1,000 stings. The aim of this study is to present an updated review of AKI associated with bee stings, including the currently advised clinical approach.

In the American continent, honeybee envenomation is a public health problem due to the high incidence and severity of the cases. Despite its medical importance, there is a lack of epidemiological studies on this topic in Brazil, especially referring to the Northeastern states. The present study has aimed to describe the epidemiological features of honeybee envenomation cases in the state of the Ceará, Northeastern Brazil, from 2007 to 2013. Data were collected from the Injury Notification Information System database of the Health Department of Ceará. A total of 1,307 cases were analyzed. Cases were shown to be distributed in all the months of the studied years, reaching higher frequencies in August. The majority of cases occurred in urban areas and involved men aged between 20 and 29 years. Victims were mainly stung on the head and torso, and they received medical assistance predominantly within 3 hours after being stung. Local manifestations were more frequent than systemic ones. Most cases were classified as mild and progressed to cure. The high number of honeybee sting cases shows that Ceará may be an important risk area for such injuries. Moreover, the current study provides data for the development of strategies to promote control and prevention of bee stings in this area.

Envenoming syndrome from Africanized bee stings is a toxic syndrome caused by the inoculation of large amounts of venom from multiple bee stings, generally more than five hundred. The incidence of severe toxicity from Africanized bee stings is rare but deadly. This report reveals that because of the small volume of distribution, having fewer stings does not exempt a patient from experiencing an unfavorable outcome, particularly in children, elderly people or underweight people.

Introduction: In 1956, Africanized honeybees (AHB) migrated from Brazil to other regions of the Western Hemisphere, including South, Central, and North America, except for Canada. Despite being productive, they are highly aggressive and cause fatal accidents. This study aimed to evaluate patients at the Clinical Hospital of Botucatu Medical School (HC-FMB) and to propose treatment guidelines., Methods: From 2005 to 2006, the clinical and laboratorial aspects of 11 patients (7 male and 4 female) and the anatomopathological aspects of one patient who had died in 2003 were analyzed., Results: The age of the surviving patients varied from 5 to 87 years, with a mean of 42.5 years. The majority of accidents occurred in the afternoon, and the number of stings ranged from 20 to 500. The principal signs and symptoms were pain and local inflammatory signs, nausea, tachycardia, and vomiting. Biochemical findings presented increased levels of creatine phosphokinase, lactate dehydrogenase, and aspartate/alanine aminotransferase. An 11-year-old male patient died upon entering the attic of a two-story building where he was attacked by a swarm, receiving more than 1,000 stings. He was sent to HC-FMB where he was treated, but he died 24h later. Observed at the autopsy were erythematous-purpuric skin lesions besides necrosis at the sting locations, rhabdomyolysis, focal myocardial necrosis, tubular hydropic degeneration and focal tubular acute necrosis of the kidneys, myoglobinuria, and centrolobular necrosis in the liver., Conclusions: Accidents caused by multiple AHB stings always constitute a medical emergency. As there is no specific antivenom, we have developed guidelines, including first aid, drugs, and the proper removal of stingers.

Massive envenomation by honey bees is capable of causing multiorgan dysfunction as a result of direct toxic effect of massive envenomation and secondary to systemic anaphylactic reactions. Acute myocardial ischemia due to bee envenomation is a rare event. We report the case of a 65 year old lady who presented with acute myocardial ischemia, severe rhabdomyolysis and angioedema following massive bee envenomation.

Although bee stings can cause local reactions, neurovascular complications are rare. A 60-year-old man developed a focal neurologic deficit 2 hours after multiple bee stings, which was confirmed to be acute cerebral infarctions on magnetic resonance imaging scan.

Preexisting cardiovascular disease may worsen the course of anaphylaxis. This is illustrated based on the example of Hymenoptera venom allergy. Fatal sting anaphylaxis is most often observed in elderly patients. During autopsy preexisting cardiovascular disease is frequently found. Preexisting cardiovascular disease in patients with anaphylaxis may also cause lasting morbidity, e.g. cerebral or myocardial infarction. Heart medications, notably beta-blockers und ACE-inhibitors may worsen the course of anaphylactic reactions due to their pharmacologic effects. Since cardiovascular diseases are much more frequent than anaphylaxis and these medications are very effective, these drugs cannot be substituted in patients with both diseases without a careful risk analysis. Epinephrine is the drug of first choice for treatment of anaphylaxis. It may however, especially following rapid intravenous administration, cause severe arrhythmias or myocardial infarction. Adrenaline should therefore preferably be given intramuscularly, or by slow intravenous infusion.

About 30 species of eusocial Apinae and 11 species of eusocial Polistinae and Vespinae are possible inducers of venom allergies in Germany. Twenty-three of these species occur regularly or occasionally in residential or recreational areas. Geographical and altitudinal distribution, phenology, nest sites and foraging habitats of these species are concisely characterized. Their defensive behavior is described.

Venom immunotherapy (VIT) protects patients with Hymenoptera venom anaphylaxis from subsequent potentially life-threatening reactions. The most important side effect are systemic anaphylactic reactions (SAR). Compared to the administration of aqueous extracts according to a rush protocol, the frequency of systemic and also local side effects will be lower if depot extracts are used and a slow conventional dose schedule is used, as compared to rush desensitization with aqueous extracts. However, protection often has to be achieved rapidly, and adequate surveillance of sufficient duration is hardly feasible in outpatients. Therefore, VIT according to rush schedules in inpatients remains indispensable. Pre-treatment with H(1)-blocking antihistamines reduces frequency and intensity of local and mild systemic adverse reactions during VIT. Up to 25% of patients again develop a SAR when re-stung while on VIT with the usual maintenance dose of 100 microg venom. Patients with honeybee venom allergy or with mastocytosis are at a higher risk for treatment failure. Almost all of them will become fully protected by increasing the maintenance dose, 200 microg venom being sufficient in most cases. Patients with significant risk factors may be treated from the beginning with an elevated maintenance dose, particularly when they are allergic to honeybee venom.

Hymenopterid stings and subsequent allergic reactions are a common indication for emergency department visits worldwide. Unrecognized anaphylactic reactions to hymenopterid stings by apids, or bees, and vespids, or wasps, are a significant cause of sudden and unanticipated deaths outdoors in young people, with and without atopic histories. Insect bites and stings, often complicated by allergic reactions or skin infections, by community-acquired pathogens, such as methicillin-resistant Staphylococcus aureus, are common sources of morbidity following hurricanes, tropical storms, and prolonged flooding. This article will review and critically analyze the descriptive epidemiology and outcomes of hymenopterid bites, stings, and allergic reactions, especially following hurricanes and prolonged flooding disasters; stratify the immunologic reactions to hymenopterid stings by clinical severity and outcomes; and present current recommendations for management, prophylaxis, and prevention of hymenopterid stings and reactions.

Hymenoptera are the large group of insects which includes honey-bees, bumble-bees, paper wasps, hornets, ants. Female hymenoptera possess specialized stinging apparatus with which they inject their venom into prey's or intruder's body. It could be life-threatening for people sensitive to the venom. The hymenoptera venom consists of mixture of biologically active substances, eg. enzymes (phospholipases, hialuronidase), peptides (melittin, apamin, mastoparans, bombolitins) and low-molecular-weight compounds (biogenic amines, acetylcholine, carbohydrates, lipids, free amino acids). Several types of reactions are possible to develop after stinging by hymenopteran insects: (1) non-allergic local reaction (pain, small oedema, redness at the site of the sting); allergic reactions: (2) large local reaction (extensive local swelling, exceeding 10 cm, persisting longer than 24 hours) and (3) anaphylaxis (generalized urticaria, bronchospasm, hypotension, cardiovascular collapse, loss of consciousness); (4) systemic toxic reaction (oedema, vomits, diarrhoea, headache, hypotension, seizures, altered mental status); (5) unusual reactions (cardiac ischaemia, encephalomyelitis et al.). Therapeutic management after stings includes removing of the stinger (bee stings), local remedies (ice-packs, topical steroids) and prevention and treatment of an anaphylactic shock (epinephrine, general steroids, beta-mimetics, fluid resuscitation, oxygen therapy). In the present review types of reaction after hymenoptera stings were described with special interest of anaphylactic and toxic reactions as well as therapeutic management after stings.

The medically important groups of Hymenoptera are the Apoidea (bees), Vespoidea (wasps, hornets, and yellow jackets), and Formicidae (ants). These insects deliver their venom by stinging their victims. Bees lose their barbed stinger after stinging and die. Wasps, hornets, and yellow jackets can sting multiple times. Most deaths related to Hymenoptera stings are the result of immediate hypersensitivity reactions, causing anaphylaxis. Massive envenomations can cause death in nonallergic individuals. The estimated lethal dose is approximately 20 stings/kg in most mammals. Anaphylactic reactions to Hymenoptera stings are not dose dependent or related to the number of stings. Bee and wasp venoms are made up primarily of protein. Conversely, fire ant venoms are 95% alkaloids. Four possible reactions are seen after insect stings: local reactions, regional reactions, systemic anaphylactic responses, and less commonly, delayed-type hypersensitivity. Clinical signs of bee and wasp stings include erythema, edema, and pain at the sting site. Occasionally, animals develop regional reactions. Onset of life-threatening, anaphylactic signs typically occur within 10 minutes of the sting. Diagnosis of bee and wasp stings stem from a history of potential contact matched with onset of appropriate clinical signs. Treatment of uncomplicated envenomations (stings) consists of conservative therapy (antihistamines, ice or cool compresses, topical lidocaine, or corticosteroid lotions). Prompt recognition and initiation of treatment is critical in successful management of anaphylactic reactions to hymenopteran stings. Imported fire ants both bite and sting, and envenomation only occurs through the sting. Anaphylaxis after imported fire ant stings is treated similarly to anaphylactic reactions after honeybee and vespid stings. The majority of Hymenopteran stings are self-limiting events, which resolve in a few hours without treatment. Because life-threatening anaphylactic reactions can progress rapidly, all animals stung should be closely monitored and observed. In the following review article, we will examine the sources and incidence, toxicokinetics, pathological lesions, clinical signs, diagnosis, treatment, and prognosis for dogs and cats suffering Hymenoptera stings.

Purpose of Review: Field stings by bumblebees are uncommon because of the habitat and nonaggressiveness of these insects. More stings have been reported in the Netherlands because of the increasing use of bumblebees in flowering industries such as tomato growing. The purpose of this review is to summarize the recent literature concerning bumblebee anaphylaxis and describe our own experience with immunotherapy in an occupational group of bumblebee-venom-allergic workers., Recent Findings: Two distinct categories of patients are sensitized to bumblebee venom. First are patients with IgE highly cross-reactive with honeybee venom allergens. Venom immunotherapy with honeybee venom will be adequate in these nonprofessionally exposed bumblebee-allergic patients. These patients react to bumblebee venom as a result of a primary earlier exposure and sensitization to honeybee venom. Secondly, with heavily exposed greenhouse workers or bumblebee workers, frequently stung only by bumblebees, it is recommended to use immunotherapy with purified bumblebee venom, due to the low or absent degree of cross-reactivity with honeybee venom. Otherwise, the best preventive therapy is to avoid further exposure, which means changing profession., Summary: Immunotherapy with purified bumblebee venom is as well tolerated and effective as immunotherapy with other Hymenoptera venoms.

Objective: To investigate the change of serum tumor necrosis factor-alpha (TNFalpha) and endothelin (ET) levels and their clinical significance in patients with bee sting poisoning., Methods: TNFalpha and ET were measured in 97 patients with bee sting poisoning and the results were compared with those in 35 healthy controls. The 97 patients were divided into three groups i.e. mild poisoning group, moderate poisoning group and severe poisoning group and they were also divided according to prognosis into death group and survival group., Results: The levels of serum TNFalpha (1.36 +/- 0.37) microg/L and ET (55.20 +/- 12.60) ng/L in the slight poisoning group increased a little, but they were not significantly different from those in the controls (1.09 +/- 0.25) microg/L and (50.90 +/- 8.80) ng/L (P > 0.05). In the moderate and severe poisoning groups the levels of serum TNFalpha (2.82 +/- 0.79) microg/L, (4.02 +/- 0.93) microg/L and plasma ET (139.30 +/- 58.80) ng/L, (210.50 +/- 86.30) ng/L were significantly higher than those in the controls (P < 0.01). The levels in the severe poisoning group were much higher than those in the moderate poisoning group and the latter much higher than those in the controls. The levels of serum TNFalpha (4.53 +/- 0.89) microg/L and plasma ET (267.50 +/- 98.70) ng/L in the death group were much higher than those in the survival group (2.40 +/- 0.82) microg/L, (107.60 +/- 57.90) ng/L (P < 0.01). The levels of serum TNFalpha were positively correlated with those of plasma ET (P < 0.01)., Conclusions: TNFalpha and ET may be involved in the pathogenesis of bee sting poisoning. It is shown that the higher the levels of serum TNFalpha and plasma ET, the severer degree of the poisoning and the higher fatality rate. Serum TNFalpha and plasma ET levels may be important clinical index in judging the patients, condition and their prognosis in bee sting poisoning. It was an important clinical significance, that may be useful for medicating with antagonist and inhibitor against TNFalpha and ET to prevention and depress death rate in the patients with bee sting poisoning.

The spread of Africanized bees in the American continent has increased the number of severe envenomation after swarm attacks. Acute renal failure (ARF) is one of the major hazards in surviving patients. To assess the mechanisms of bee venom-induced ARF, rats were evaluated before, up to 70 min and 24h after 0.5mg/kg of venom injection. Control rats received saline. Bee venom caused an early and significant reduction in glomerular filtration rate (GFR, inulin clearance, 0.84+/-0.05 to 0.40+/-0.08 ml/min/100g, p<0.0001) and renal blood flow (RBF, laser Doppler flowmetry), which was more severe in the cortical (-72%) than in the medullary area (-48%), without systemic blood pressure decrease. Creatine phosphokinase, lactic dehydrogenase (LDH) and serum glutamic oxaloacetic transaminase increased significantly, pointing to rhabdomyolysis, whereas serum glutamic pyruvic transaminase and hematocrit remained stable. Twenty-four hours after venom, RBF recovered but GFR remained significantly impaired. Renal histology showed acute tubular injury and a massive tubular deposition of myoglobin. Venom was added to isolated rat proximal tubules (PT) suspension subjected to normoxia and hypoxia/reoxygenation (H/R) for direct nephrotoxicity evaluation. After 60 min of incubation, 0.1, 2 and 10 microg of venom induced significant increases in LDH release: 47%, 64% and 86%, respectively, vs. 21% in control PT while 2 microg of venom enhanced H/R injury (85% vs. 55%, p<0.01). These results indicate that vasoconstriction, direct nephrotoxicity and rhabdomyolysis are important mechanisms in the installation of bee venom-induced ARF that may occur even without hemolysis or hypotension.

Massive envenomations by honey bees are capable of causing multiorgan dysfunction as a result of the direct toxic effects of the large venom load received. Although all varieties of honey bee have the potential for these attacks, the Africanized honey bee (Apis mellifera scutellata) is the most commonly implicated subspecies. In the United States, the Africanized strain is found primarily in the southwestern states and is known for its highly defensive behavior if disturbed. Mechanisms behind the multiorgan dysfunction produced by these mass envenomations are not clearly understood. We present a case of a 13-year-old male who was stung by approximately 700 honey bees and developed progressive upper-body swelling and systemic manifestations of mass envenomation including rhabdomyolysis, renal insufficiency, and a transient transaminase elevation.

Although severe reactions to the sting of the common honey bee (Apis mellifera) are a common problem in Australia, reported deaths are uncommon, with the estimated mortality varying from one to four persons each year. The following study presents the postmortem findings in three cases of bee sting fatality, including one in which no observable sting was found. An autopsy approach to such cases is detailed. Overreporting of bee sting-related deaths may occur due to the inclusion of deaths unrelated to a reaction to bee venom, while under-reporting may be due to unexplained deaths where a history of a bee sting is not available or apparent at autopsy. A classification of bee sting-related deaths is proposed, which would allow more accurate reporting of bee sting-related fatalies. A serum tryptase and specific IgE to bee venom on serum obtained at autopsy can assist in confirming anaphylactic reaction to bee venom as the cause of death, particularly in the absence of observable stings. Although there are limitations to the usefulness of serum tryptase tests in the postmortem situation, it may still be useful to confirm suspected anaphylaxis in autopsy cases with an undetermined cause of death.

Massive bee envenomation can produce both immediate and delayed toxic reaction. Signs and symptoms of immediate toxic reaction are fatigue, nausea, vomiting, hemolysis, kidney failure, and disseminated intravascular coagulation. The label "delayed toxic reaction" refers to a patient who is asymptomatic after a massive bee envenomation, with normal initial laboratory results, but later demonstrates laboratory evidence of hemolysis, coagulopathy, thrombocytopenia, rhabdomyolysis, liver dysfunction, and disseminated intravascular coagulation. The subject of this case report, a 66-year-old man, was stung more than 125 times in an attack by Africanized bees. He was initially asymptomatic, except for pain, and his laboratory findings were normal. The first signs of his fatal multi-organ-system failure were not apparent until 18 hours after envenomation. This experience has led the Good Samaritan Regional Poison Center in Phoenix, AZ, to recommend a 24-hour hospitalization for pediatric patients, older patients, and patients with underlying medical problems who are asymptomatic or who are experiencing only pain after an envenomation of 50 or more stings. Such patients have an increased risk of tissue injury, which may be delayed and which may be more effectively treated if identified early rather than on 12- to 24-hour follow-up. All other envenomated, asymptomatic patients or envenomated patients experiencing only pain who become symptomatic or who belatedly exhibit laboratory values consistent with hemolysis, thrombocytopenia, rhabdomyolysis, liver dysfunction, kidney failure, and disseminated intravascular coagulation within a 6-hour emergency department observation period should be admitted. Intravenous fluids, blood products, dialysis, and other intensive measures should be initiated if necessary.

Clinical symptoms of toxic reactions occurred in two patients following multiple stinging by bees and wasps respectively. The first cause is that of 76-year old woman attacked by a swarm of bees (about 200 stings), the other case presents a 69-year old man who was stung by several dozen of wasps. In the first case the toxic reaction was manifested by shock, acute renal failure, tissue damage of the skin, muscles and liver and haemolysis which resulted in the patients death. These symptoms occur as a results of the cytotoxic effects of bee venom components such as melittin, phospholipase and kinins. In the course of the disease, noteworthy are: the initial phase mimicking an anaphylactic shock, haemolysis and rhabdomyolysis which lead to acute renal failure with tubular necrosis. In the second case skin symptoms prevailed. Additionally, laboratory tests showed increased CPK as a results of myolysis caused by components of insect venom. The progress of toxic reactions following multiple stinging especially by bees, calls for hospital observation of stung patients with careful monitoring of renal function.

Background: Bee stings can cause severe toxic effects when envenomation is massive., Case Report: While touring in Casamance (Southern Senegal) a white male was severely stung by a swarm of African bees. The massive envenomation caused rhabdomyolysis, hemolysis and acute renal failure. Pathology examination of kidney and bladder specimens showed vasculitis affecting both arteries and veins. The patient was treated with several hemodialysis sessions and renal function returned to normal three months after the incident., Discussion: Bees in Africa, known as "killer bees", are particularly aggressive. They have recently been imported from tropical zones in America where a large number of deaths have been reported. Most cases of massive envenomation have shown acute tubular necrosis or renal involvement with myoglobinuria or hemoglobinuria. The renal pathology observed in our case is not usually described.

Two cases of poisoning produced by the unusual attack of colonies of insects from the family Bombidae, commonly known as bumblebees, are described. This type of poisoning may become severe toxicity and it is analyzed in the light of the latest findings. It is characterized by hemorrhagical symptoms, such as hematemesis and melaena.

Background: Mortality secondary to insect sting anaphylaxis, though uncommon in this country, is a genuine risk to patients with venom hypersensitivity. A number of non specific and specific preventive measures are available to minimise this risk. They include proper patient counselling regarding sting avoidance and the use of self injectable adrenaline, as well as venom specific immunotherapy., Objective: This article attempts to review the spectrum of insect sting reactions, their appropriate assessment and subsequent management. Anaphylaxis is particularly emphasised with regard to first aid treatment and subsequent prevention., Discussion: The most common causes of insect stings in Australia are bees and wasps. Insect sting reactions cover a spectrum of responses, from normal to anaphylactic. Immunotherapy is indicated in those patients who experience anaphylactic responses. The presence of venom specific IgE must be demonstrated before commencing immunotherapy. Venom sensitive patients should be educated in anaphylaxis first aid with adrenaline self injectable syringes.

Background: Conventional advice on immediate treatment of honey-bee stings has emphasised that the sting should be scraped off, never pinched. The morphology of the sting suggested little basis for this advice, which is likely to slow down removal of the sting., Methods: The response to honey-bee stings was assayed with a measurement of the size of the resulting weal. Injection of known quantities of venom showed that this measurement is a good indicator of envenomisation., Findings: Weal size, and thus envenomisation, increased as the time from stinging to removal of the sting increased, even within a few seconds. There was no difference in response between stings scraped or pinched off after 2 s., Interpretation: These data suggest that advice to patients on the immediate treatment of bee stings should emphasise quick removal, without concern for the method of removal.

The syndrome of bee-sting anaphylaxis is described. Children who have suffered crescendo reactions to previous bee stings, especially children with a history of asthma, are significantly at risk. Desensitization is required in such cases; adrenaline should be kept in the home, and parents should be trained in its emergency use. The immunological mechanisms of bee-sting anaphylaxis are described. The striking seasonal incidence of anaphylaxis suggests that pollen or plant products which are incorporated in the venom may also be important in its genesis; it suggests also that antigens prepared from either whole-body or pure-venom extracts should be prepared from bees which are collected in late spring.