Stinging Insect Reactions: Who Needs Referral?

Selected by Pietro Cazzola

BeeRecognizing which patients with even a breathtakingly dramatic reaction to a hymenoptera sting can be appropriately managed by their primary care physician and which ones need referral to an allergy specialist is the key to avoiding a potential lawsuit that’s essentially indefensible.
A patient needs referral for allergy testing and desensitization therapy only if the swelling or hives occurred in a discontinuous pattern from the site of the sting or if there was anaphylaxis. Otherwise the patient is best managed in his or her medical home by a primary care physician using reassurance, a short course of oral prednisone and, if infection is present, a beta-lactam antibiotic, Dr. Mark A. Ebadi said at a conference on internal medicine sponsored by the University of Colorado.
“I see a patient with an incredibly swollen hand, neck, or leg due to a hymenoptera sting every day during the summer. I tell patients that if you’re stung on the hand, even if it swells all the way up your arm and into your neck, that’s still a local reaction. That does not portend an anaphylactic reaction the next time you get stung. You’re supposed to react to a hymenoptera sting, it’s not a big deal,” explained Dr. Ebadi of the Colorado Allergy and Asthma Center, Denver.
On the other hand, a patient who got stung on the foot and minutes later experienced facial swelling in a discontinuous pattern, perhaps accompanied by widespread hives and difficulty breathing, has had a systemic reaction with production of IgE in response to hymenoptera of some kind.
“The standard of care in internal medicine for hymenoptera anaphylaxis is referral to a specialist for testing and allergen desensitization. You don’t have a leg to stand on if you just give the patient an epi pen and tell them to keep it with them at all times, and then they get stung when they forgot to carry it and they get laryngeal angioedema, airway compromise, and die. I see cases like that probably twice a year when attorneys consult with me. I’ll review the chart and tell the attorney, ‘You should probably settle,’ ” the allergist continued.
For the results of RAST (radioallergosorbent) testing to be meaningful, the testing should be delayed until 1 month after the sting. It’s an excellent idea to give the patient an epi pen and instructions to carry it at all times while waiting for the specialist appointment, he added.

Dr. Ebadi reported having no financial conflicts of interest.