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Aziz Sheikh and Samantha Walker
Anaphylaxis
BMJ 2005; 331: 330 [Full text]
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Rapid Responses published:

[Read Rapid Response] Kounis Syndrome and Anaphylaxis from Hymenoptera Stings
Nicholas G. Kounis, George Kounis MD, Sophia Kouni MSc   (9 August 2005)
[Read Rapid Response] Adrenaline dose in Anaphylaxis in patients on beta blocking drugs
Myles R Milhench   (11 August 2005)
[Read Rapid Response] Risk of anaphylaxis to hymenoptera stings after an initial event
Michal R. Pijak, Frantisek Gazdik, Katarina Gazdikova   (23 August 2005)
[Read Rapid Response] Please don't use the "C-word"
Diane-Marie Campbell   (26 August 2005)

Kounis Syndrome and Anaphylaxis from Hymenoptera Stings 9 August 2005
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Nicholas G. Kounis,
Professor of Medicine
Medical Sciences, Patras Highest Institute of Education and Technology, 7 Aratou Street, Queen Olgas,
George Kounis MD, Sophia Kouni MSc

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Re: Kounis Syndrome and Anaphylaxis from Hymenoptera Stings

Reactions that pose great risk from hymenoptera stings are those involving the cardiovascular or respiratory system or both as emphasized by Sheikh and Walker(1). Kounis syndrome(2) is the concurrence of acute coronary syndromes with acute hypersensitivity or anaphylactic reactions.

This syndrome was initially described as ``allergic angina syndrome``(3) progressing to ``allergic myocardial infarction``(4). In a recent study(5) by pushing a single ant against the ventral forearm of 21 healthy volunteers, allowing it to sting for 60 seconds, two of the subjects developed chest pain with electrocardiographic changes suggestive of acute myocardial ischaemia. Although many cases of hymenoptera-induced Kounis syndrome might go unreported, searching the literature via medline showed 26 reports of acute myocardial infarction and 6 of cerebral infarction following wasp stings. Sheikh and Walker(1) suggest the use of self administered adrenaline for emergency treatment. However, in a sulfite allergic patient adrenaline should be avoided because every commercially available adrenaline preparation contains sodium metabisulfite. Sodium metabisulfite is a commonly used food and drug preservative. Methoxamine, a potent alpha agonist should be an alternative.

References

1. Sheikh A, Walker S. 10-minute consultation. Anaphylaxis 2005; 331: 330.

2. Zavras GM Papadaki PJ, Kokkinis CE, et al. Kounis syndrome secondary to allergic reaction following shellfish ingestion. Int J Clin Pract 2003; 57: 622-624.

3. Soufras GD, Ginopoulos PV, Papadaki PJ, et al. Penicillin allergy in cancer patients manifesting as Kounis syndrome. Heart Vessels 2005; 20: 159-163.

4. Mazarakis A, Kotsojannis CM, Kounis NG, et al. Cefuroxime-induced coronary artery spasm manifesting as Kounis syndriol 2005; 60: 341-345.

5. Brown SGA, Blackman KE, Stenlake V, et al. Insect sting anaphylaxis; prospective evaluation of treatment with adrenaline and volume resuscitation. Emerg Med J 2004; 21: 149-154.

Competing interests: None declared
Adrenaline dose in Anaphylaxis in patients on beta blocking drugs 11 August 2005
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Myles R Milhench,
consultant anaesthetist
downe hospital downpatrick bt30 6ja

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Re: Adrenaline dose in Anaphylaxis in patients on beta blocking drugs

Editor, I enjoyed the article on anaphylaxis by Sheikh and Walker, and they correctly drew attention to the difficulties associated with treating anaphylaxis with adrenaline in patients on non cardiac selective Beta - adrenoceptor Blocking drugs.However it is important to remember that although some Beta-adrenoceptor Blocking drugs are relatively cardioselective they are not cardiospecific.

The dose of adrenaline used to treat anaphylaxis in patients taking Beta- adrenoceptor Blocking drugs should be half the normal dose to avoid the serious side effects associated with the unopposed Alpha-adrenoceptor stimulation caused by adrenaline in patients on Beta-adrenoceptor blocking drugs , which could result in hypertension,coronary artery constriction and bronchoconstriction.

It would be better to try to avoid Beta-adrenoceptor Blocking drugs completely in patients at risk of repeated anaphylaxis.

Myles R.Milhench.
Consultant Anaesthetist.

Competing interests: None declared
Risk of anaphylaxis to hymenoptera stings after an initial event 23 August 2005
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Michal R. Pijak,
Consultant in Internal Medicine, Rheumatology and and Clinical Immunology
University Hospital, 83101 Bratislava, Slovakia,
Frantisek Gazdik, Katarina Gazdikova

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Re: Risk of anaphylaxis to hymenoptera stings after an initial event

The article by Sheikih and Walker(1) on the management of recent allergic reaction to an insect sting contains several puzzling statements.

First, the statement that “Reactions to further stings are unpredictable” is misleading. Large prospective studies, which also included adults confirmed that future reactions in the same patient usually follow the same pattern.(2,3) The chance of severe systemic reaction(SR) to a future sting in adults with a history of severe anaphylaxis is 60% to 70% but in those with mild SR only 20%.(4,5) The risk of SR in patients with a history of large local reactions is no more than 5% to 10%.(6,7) These data support the current guidelines to focus the provision of adrenaline auto-injectors and venom immunotherapy on people with a history of severe SR.(8)

Second , the notion that “venom allergy is unrelated to atopy” is based on several flawed studies which failed to take into account differences in the degree of exposure (patients with anaphylaxis having higher degree of exposure then control group) causing underestimation of the association. Although sting allergy frequently affects non-atopic subjects, studies in beekeepers show that frequency of SR is higher in atopic individuals (up to 48%), who are also predisposed to more severe reactions. (9,10) Other studies have shown that sensitization to stings correlate positively with atopy.(11-13)

Finally, the authors overlooked that 30% to 50% of all patients with stinging-insect allergy have double-positive CAP-RAST results to honeybee and wasp venom.(14) Although true double-sensitization may account for these results, recent data suggest that cross-reactivity through carbohydrate epitopes is a major cause for this multiple IgE reactivity.(15) FEIA inhibition test may be helpful in discriminating between truly double-sensitized patients who may require immunotherapy with 2 venoms and patients with cross-reacting IgE, for whom restriction of immunotherapy to one venom is beneficial and cost- effective.(16)

1. Sheikh A, Walker S. Anaphylaxis. BMJ 2005;331:330.

2. van der Linden PW, Struyvenberg A, Kraaijenhagen RJ, Hack CE, van der Zwan JK. Anaphylactic shock after insect-sting challenge in 138 persons with a previous insect-sting reaction. Ann Intern Med 1993;118:161 -8.

3. Brown SG, Franks RW, Baldo BA, Heddle RJ. Prevalence, severity, and natural history of jack jumper ant venom allergy in Tasmania. J Allergy Clin Immunol 2003;111:187-192.

4. Hunt KJ, Valentine MD, Sobotka AK, Benton AW, Amodio FJ, Lichtenstein LM. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978;299:157-61.

5. Reisman RE. Natural history of insect sting allergy: relationship of severity of symptoms of initial sting anaphylaxis to re-sting reactions. J Allergy Clin Immunol 1992;90:335-9.

6. Mauriello PM, Barde SH, Georgitis JW, Reisman RE. Natural history of large local reactions from stinging insects. J Allergy Clin Immunol 1984;74:494-8.

7. Graft DF, Schuberth KC, Kagey-Sobotka A, Kwiterovich KA, Niv Y, Lichtenstein LM, et al. A prospective study of the natural history of large local reactions after Hymenoptera stings in children. J Pediatr 1984;104:664-8.

8. Moffitt JE, Golden DB, Reisman RE, Lee R, Nicklas R, Freeman T, et al. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol 2004;114:869-86.

9. Annila IT, Karjalainen ES, Annila PA, Kuusisto PA. Bee and wasp sting reactions in current beekeepers. Ann Allergy Asthma Immunol 1996;77:423-7.

10. Bousquet J, Coulomb Y, Robinet-Levy M, Michel FB. Clinical and immunological surveys in bee keepers. Clin Allergy 1982;12:331-42.

11. Miyachi S, Lessof MH, Kemeny DM, Green LA. Comparison of the atopic background between allergic and non-allergic beekeepers. Int Arch Allergy Appl Immunol 1979;58:160-6.

12. Schafer T, Przybilla B. IgE antibodies to Hymenoptera venoms in the serum are common in the general population and are related to indications of atopy. Allergy 1996;51:372-7.

13. Novembre E, Cianferoni A, Bernardini R, Veltroni M, Ingargiola A, Lombardi E, et al. Epidemiology of insect venom sensitivity in children and its correlation to clinical and atopic features. Clin Exp Allergy 1998;28:834-8.

14. Egner W, Ward C, Brown DL, Ewan PW. The frequency and clinical significance of specific IgE to both wasp (Vespula) and honey-bee (Apis) venoms in the same patient. Clin Exp Allergy 1998;28:26-34.

15. Hemmer W, Focke M, Kolarich D, Wilson IB, Altmann F, Wohrl S, et al. Antibody binding to venom carbohydrates is a frequent cause for double positivity to honeybee and yellow jacket venom in patients with stinging-insect allergy. J Allergy Clin Immunol 2001;108:1045-52.

16. Straumann F, Bucher C, Wuthrich B. Double sensitization to honeybee and wasp venom: immunotherapy with one or with both venoms? Value of FEIA inhibition for the identification of the cross-reacting ige antibodies in double-sensitized patients to honeybee and wasp venom. Int Arch Allergy Immunol 2000;123:268-74.

Competing interests: None declared
Please don't use the "C-word" 26 August 2005
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Diane-Marie Campbell,
locum emergency physician
Burnie, Tasmania 7320 Australia

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Re: Please don't use the "C-word"

The patient with anaphylaxis probably attended an Emergency Department. Not a Casualty. In my 25 years of practice, most in Emergency Medicine in Britain, New Zealand and Australia I have never worked in a "Casualty." I am not a "Casualty officer" and like many of my colleagues object to the use of such terms.

The hospital secretary prefers to be called the CEO so we humour him, the surgical dresser likes to be called a surgeon and we humour him. The BMJ made a commitment some years ago to use the term "Emergency" but has been careless about allowing authors to use "Casualty." Unless the local Emergency or Accident and Emergency department does call itself a "Casualty" department this is simply discourteous.

Competing interests: None declared