II. Epidemiology
- Peak Incidence in August
- Hymenoptera are most common cause of serious venom reaction (as well as for death) in U.S.
- Systemic Allergic Reaction: 5% of patients
- Anaphylaxis: <1% of patients overall (up to 3% in adults)
- Hymenoptera Stings are responsible for 17% of U.S. anaphylactic reactions overall
- Responsible for average of 62 deaths per year in U.S.
III. Types: Hymenoptera
- Hymenoptera order contains more than 100,000 species, of which only the Stinging Insects are listed here
- Usually only Insects of Hymenoptera cause Anaphylaxis
- Yellow jackets and Wasps (Vespidae family)
- Attracted to food and garbage containers
- Attack without provocation
- Stings peak in summer and autumn coinciding with population peaks
- Yellow jackets nest in the ground (crevices or burrows) or in trees or shrubs
- Wasps nest under houses, in barns, mailboxes, shrubs and tree cavities
- Disturbance of a nest may lead to attacks (>10)
- Hornets (Vespidae family)
- Nest on undersurfaces of decks and roof overhangs
- Attack in small groups (1-5) if nest disturbed
- Hornet venom is more potent and of greater volume, able to reach lethal levels with fewer stings
- Associated with higher risk of multiorgan failure and death than with other stinging Hymenoptera
- Bumblebees and Honeybees (Apidae family)
- Africanized Honeybees (Killer Bees)
- Attack in swarms of hundreds
- Pursue victims well away from the hive
- In U.S. found in Arizona, California, Nevada, New Mexico and Texas
- Fire Ants (Formicidae family, Solenopsis species)
- Fire ants are 3 to 8 mm and red-brown or black
- Nest in the ground
- Attack in swarms when nest is attacked, most typically on extremities
- Circular cluster of 6 to 7 stings is common
- Stings may result in immediate and delayed Hypersensitivity Reactions
IV. History
- Prior prior Allergic Reaction history (including Insect sting reactions)
- Current sting attack history
- Events leading up to the sting
- Number of sting sites and their location
- Stinging Insect species (see above, if patient able to identify)
V. Signs: Local Reactions
- Most reactions have onset in minutes and hours and resolve within 24 hours
- Bees/Wasps (Venom contains biogenic amines)
- Fire ants (Venom contains alkaloids)
- Arc shaped lesions or circular grouping of 6-7 stings
- Sterile Pustules develop within 24 hours
- Honeybee
- Barbed Stinger remains in skin after sting
- Injection continues until Stinger removed (although most venom is injected in first minute)
- Do NOT grasp Stinger - will inject more venom
- Retained Stinger may also lead to Foreign Body Granuloma and risk for secondary infection
- Technique to remove Stinger
- Scrape sharp object (knife) horizontally over skin
- Drags Stinger out intact
- Barbed Stinger remains in skin after sting
VI. Signs: Large Local Reaction
- Represents 19% of reactions
- Onset in first few days and resolves by 7 days after sting
- Erythema and induration >10 cm (>4 inches, up to 8 to 10 inch diameter)
- May be difficult to differentiate from a secondary infection
- Risk of future systemic reaction: 5 to 10%
VII. Signs: Systemic Reaction
- See Allergic Reaction
- See Anaphylaxis
- Systemic Reaction or Anaphylaxis (responsible for 17% of all anaphylactic reactions)
- See Anaphylaxis for management
- IgE mediated reaction with Angioedema, Urticaria, respiratory distress
- Onset of reaction within 20 minutes of sting
- Delayed Hypersensitivity
- Reactions include Serum Sickness, Vasculitis, Glomerulonephritis, cerebral edema, DIC, Arthritis
- Rare complication of Insect Bite
- Occurs 3-14 days after large dose of venom
- Arthralgia and fever
- Massive Envenomation
- Rhabdomyolysis
- Multiorgan failure (renal, hepatic)
- Hemolysis
- Seizures
- Pancreatitis
VIII. Complications (rare - case reports)
- Vasculitis
- Nephritis
- Neuritis
- Encephalitis
- Myocarditis
- Guillain-Barre Syndrome
IX. Differential Diagnosis
- See Insect Bite
X. Management: Reaction
-
General measures
- Remove Stingers still embedded in skin
- Avoids further Envenomation (esp. honeybee, bumblebee) and foreign body reaction
- Use a card or dull blade to scrape over the sting site (parallel to Stinger) to dislodge the Stinger
- Avoid squeezing the Stinger with forceps (injects more venom)
- Tetanus Vaccination is not needed for Hymenoptera Stings
- Remove Stingers still embedded in skin
- Systemic Allergic Reaction or Anaphylaxis Management
- See Anaphylaxis for management
- See Allergic Reaction
- Epinephrine 0.01 mg/kg (of 1 mg/ml solution) up to 0.3 mg in children and 0.5 mg in adults
- Other Anaphylaxis management includes ABC Management, Bronchodilators, Antihistamines, Intravenous Fluid
- BIphasic Reaction (uncommon)
- Mild to severe Anaphylaxis reccurs within 72 hours of initial reaction
- More likely in those requiring more than one dose of Epinephrine
- Observe for 6 to 24 hours
- Recurrent systemic reaction in 50% of cases from future Hymenoptera Sting
- Reaction is specific to the 3 types: Bees, Fire Ants or Vespidae (wasps, hornets, yellow jackets)
- Prescribe Epinephrine Autoinjector for those with anaphylactic reaction
- Systemic reaction risk is reduced to 3% risk with Desensitization
- Severe reaction is highest risk in small children, elderly or multiple stings
- Local Reaction
- Ice Packs or cool compresses
- Analgesics (e.g. NSAIDs, Acetaminophen)
- Unproven efficacy of other agents
- Antihistamines (e.g. Zyrtec)
- Topical Corticosteroids
- Topical papain (meat tenderizer) or Baking Soda
- Large Local Reaction
- Differentiate from Cellulitis and other vector borne conditions (e.g. Erythema Migrans)
- Prednisone or Methylprednisolone 1 to 2 mg/kg (children) up to 40 to 60 mg (adults) for 3 o 5 days
- Massive Envenomation (e.g. >100 stings)
- Results in direct venom toxicity
- Risk of cardiovascular collapse, Rhabdomyolysis, multisystem organ failure
- ABC Management and other supportive care
- Delayed Hypersensitivity or Serum Sickness
- Supportive care
- Systemic Corticosteroids
- Antihistamines
XI. Prevention
- See Stinging Insect Immunotherapy
-
General
- Avoid floral print clothing
- Avoid floral fragrances
- Avoid walking barefoot
- Remove wasp and hornet nests when identified
- Cleanse outdoor garbage cans
- Clean eating areas of food remains
- Close food sources
- Bees
- Avoid walking through flowers
- Avoid bananas around hives (similar scent to bee alarm pheromone)
- Carbon dioxide and human sweat can also Antagonize bees
- Fire Ants
- Inspect playgrounds and yards for ant mounds
- Toxic bait may target queen ant
XII. References
- Cowling and Ferreri (2019) Crit Dec Emerg Med 33(2): 17-25
- Cowling and Lowes (2024) Crit Dec Emerg Med 38(1): 4-13
- Herness (2022) Am Fam Physician 106(2): 137-47 [PubMed]
- Kemp (1998) J Postgrad Med 103(6):88-106 [PubMed]
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Related Studies
Definition (MSH) | Insect members of the superfamily Apoidea, found almost everywhere, particularly on flowers. About 3500 species occur in North America. They differ from most WASPS in that their young are fed honey and pollen rather than animal food. |
Definition (MSHCZE) | Hmyz z nadčeledi Apoidea, který se nachází téměř všude, obzvláště na květech. V Severní Americe se vyskytuje asi 3500 druhů. Od většiny VOS se liší tím, že své potomstvo krmí spíše medem a pylem než živočišnou potravou. |
Concepts | Eukaryote (T204) |
MSH | D001516 |
SnomedCT | 106820008, 31141000009100, 28482008 |
Swedish | Bin |
Czech | včely |
Finnish | Mehiläiset |
Russian | PCHELY, ПЧЕЛЫ |
English | Bees, bee, bees, Family apoidea - bee (organism), Superfamily Apoidea (organism), Apoidea, Superfamily Apoidea, Bee, Family apoidea - bee, Bee (organism), Bee, NOS |
Croatian | PČELE |
French | Abeilles |
Polish | Pszczoły |
Spanish | familia apoidea - abeja (concepto no activo), familia apoidea - abeja, Jalea Real, abeja (organismo), abeja, Abejas |
Norwegian | Bier |
Portuguese | Geleia Real, Abelhas |
German | Bienen |
Italian | Api |
Dutch | Bij, Bijen |
Ontology: Hymenoptera (C0020415)
Definition (MSH) | An extensive order of highly specialized insects including bees, wasps, and ants. |
Definition (CSP) | order of insects, including bees, wasps, and ants, characterized by high development of social or colonial behavior and usually by locked pairs of membranous wings. |
Concepts | Eukaryote (T204) |
MSH | D006927 |
SnomedCT | 106819002 |
English | Hymenoptera, Order hymenoptera (organism), Order Hymenoptera (organism), Order Hymenoptera, Order hymenoptera, Hymenopteras, hymenoptera, hymenopterans, Order: Hymenoptera |
Spanish | orden Hymenoptera (organismo), orden Hymenoptera, orden hymenoptera (organismo), orden hymenoptera, Hymenoptera, Himenópteros |
Swedish | Hymenoptera |
Czech | Hymenoptera |
Finnish | Pistiäiset |
Russian | PEREPONCHATOKRYLYE, ПЕРЕПОНЧАТОКРЫЛЫЕ |
Croatian | Not Translated[Hymenoptera] |
French | Hymenoptera, Hyménoptères |
Polish | Błonkoskrzydłe, Błonkówki |
Norwegian | Hymenoptera |
Portuguese | Hymenoptera, Himenópteros |
German | Hymenoptera, Hautflügler |
Italian | Hymenoptera |
Dutch | Hymenoptera, Vliesvleugeligen |
Ontology: Wasps (C0043041)
Definition (MSH) | Any of numerous winged hymenopterous insects of social as well as solitary habits and having formidable stings. |
Definition (PSY) | Any of numerous social or solitary winged hymenopterous insects. |
Concepts | Eukaryote (T204) |
MSH | D014863 |
SnomedCT | 88030006 |
English | Wasps, wasps, wasp, Wasp, Wasp (organism), Wasp, NOS |
Swedish | Getingar |
Finnish | Ampiaiset |
Russian | OSY NASTOIASHCHIE, OSY, ОСЫ, ОСЫ НАСТОЯЩИЕ |
Croatian | OSE |
French | Guêpes |
Polish | Osy |
Czech | sršňovití, vosovití, vosy |
Norwegian | Vepser |
Spanish | avispa (organismo), avispa, Avispas |
German | Wespen |
Italian | Vespe |
Dutch | Wesp, Wespen |
Portuguese | Vespas |
Ontology: Stinging insect (C0348085)
Concepts | Eukaryote (T204) |
SnomedCT | 260889009, 410654005, 410655006 |
English | Stinging insect, Stinging insect (organism), Stinging insect (attribute) |
Spanish | himenópteros (organismo), himenópteros, himenópteros (atributo) |
Ontology: Wasp sting (C0413119)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 157931003, 210984001, 241819002 |
Dutch | wespensteek |
French | Piqûre de guêpe |
German | Wespenstich |
Italian | Puntura di vespa |
Portuguese | Picada de vespa |
Spanish | Picadura de avispa, picadura de avispa (trastorno), picadura de avispa |
Japanese | スズメ蜂刺傷, スズメバチサシキズ, スズメバチシショウ |
Czech | Vosí bodnutí |
English | sting wasp, stings wasps, wasp sting, Sting;wasp, stings wasp, Wasp sting, Wasp sting (disorder) |
Hungarian | Darázscsípés |
Ontology: Bee sting (C0413120)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 157930002, 210984001, 241820008 |
Dutch | bijensteek |
German | Bienenstich |
Italian | Puntura d'ape |
Portuguese | Picada de abelhas |
Spanish | Picadura de abeja, picadura de abeja (trastorno), picadura de abeja |
Japanese | 蜂刺傷, ハチシショウ, ハチサシキズ |
French | Piqûre d'abeille |
English | bee sting (diagnosis), injury caused by bee sting, bee sting, Sting;bee, bee stings, Bee Stings, Bee sting, Bee sting (disorder) |
Czech | Včelí bodnutí |
Hungarian | Méhcsípés |
Ontology: Yellow jacket causing poisoning and toxic reactions (C0867896)
Concepts | Injury or Poisoning (T037) |
English | Yellow jacket causing poisoning and toxic reactions |
Ontology: Hymenoptera sting (C1274548)
Concepts | Injury or Poisoning (T037) |
SnomedCT | 403142004 |
English | Hymenoptera sting (disorder), Hymenoptera sting |
Spanish | picadura de himenópteros (trastorno), picadura de himenópteros |