Emergency Medicine Book


Hymenoptera Sting

Aka: Hymenoptera Sting, Hymenoptera, Stinging Insect, Wasp Sting, Wasp, Bees, Bee sting, Yellow Jacket Sting, Fire Ant Sting, Stinging Insect Allergy, Hymenoptera Allergy, Stinging Insect Reaction
  1. See Also
    1. Envenomation
    2. Insect Bite
  2. Epidemiology
    1. Peak Incidence in August
    2. Hymenoptera are most common cause of serious venom reaction (as well as for death) in U.S.
      1. Systemic Allergic Reaction: 5% of patients
      2. Anaphylaxis: <1% of patients overall (up to 3% in adults)
        1. Responsible for average of 62 deaths per year in U.S.
  3. Types: Hymenoptera
    1. Hymenoptera order contains more than 100,000 species, of which only the Stinging Insects are listed here
    2. Usually only Insects of Hymenoptera cause Anaphylaxis
      1. Distinct InsectVenoms (allergy specific to the 5 types below)
    3. Yellow jackets and Wasps (Vespidae family)
      1. Attracted to food and garbage containers
      2. Attack without provocation
      3. Stings peak in summer and autumn coinciding with population peaks
      4. Yellow jackets nest in the ground (crevices or burrows) or in trees or shrubs
      5. Wasps nest under houses, in barns, mailboxes, shrubs and tree cavities
      6. Disturbance of a nest may lead to attacks (>10)
    4. Hornets (Vespidae family)
      1. Nest on undersurfaces of decks and roof overhangs
      2. Attack in small groups (1-5) if nest disturbed
      3. Hornet venom is more potent and of greater volume, able to reach lethal levels with fewer stings
      4. Associated with higher risk of multiorgan failure and death than with other stinging Hymenoptera
    5. Bumblebees and Honeybees (Apidae family)
      1. Not aggressive unless hives attacked
      2. Honey Bees (Apis) leaves a detached Stinger in the skin, and then dies shortly thereafter
      3. Bumble Bees (Bombus) do not detach their Stinger, and may sting multiple times
    6. Africanized Honeybees (Killer Bees)
      1. Attack in swarms of hundreds
      2. Pursue victims well away from the hive
      3. In U.S. found in Arizona, California, Nevada, New Mexico and Texas
    7. Fire Ants (Formicidae family, Solenopsis species)
      1. Fire ants are 3 to 8 mm and red-brown or black
      2. Nest in the ground
      3. Attack in swarms when nest is attacked, most typically on extremities
      4. Circular cluster of 6 to 7 stings is common
      5. Stings may result in immediate and delayed Hypersensitivity Reactions
  4. Signs: Local Reactions
    1. Most reactions have onset in minutes and hours and resolve within 24 hours
    2. Bees/Wasps (Venom contains biogenic amines)
      1. Erythematous Papules develop in seconds
      2. Most lesions subside in 4-6 hours
      3. Larger areas of edema and Urticaria may develop (10%, lesions may last >48 hours)
      4. Some extensive local reactions persist for days
    3. Fire ants (Venom contains alkaloids)
      1. Arc shaped lesions or circular grouping of 6-7 stings
      2. Sterile Pustules develop within 24 hours
    4. Honeybee
      1. Barbed Stinger remains in skin after sting
        1. Injection continues until Stinger removed (although most venom is injected in first minute)
        2. Do NOT grasp Stinger - will inject more venom
        3. Retained Stinger may also lead to Foreign Body Granuloma and risk for secondary infection
      2. Technique to remove Stinger
        1. Scrape sharp object (knife) horizontally over skin
        2. Drags Stinger out intact
  5. Signs: Large Local Reaction
    1. Represents 19% of reactions
    2. Onset in first few days and resolves by 7 days after sting
    3. Erythema and induration >10 cm (>4 inches, up to 8 to 10 inch diameter)
    4. May be difficult to differentiate from a secondary infection
    5. Risk of future systemic reaction: 5 to 10%
  6. Signs: Systemic Reaction
    1. See Allergic Reaction
    2. See Anaphylaxis
    3. Systemic Reaction or Anaphylaxis (responsible for 17% of all anaphylactic reactions)
      1. See Anaphylaxis for management
      2. IgE mediated reaction with Angioedema, Urticaria, respiratory distress
      3. Onset of reaction within 20 minutes of sting
    4. Delayed Hypersensitivity
      1. Reactions include Serum Sickness, Vasculitis, Glomerulonephritis, cerebral edema, DIC, Arthritis
      2. Rare complication of Insect Bite
      3. Occurs 3-14 days after large dose of venom
      4. Arthralgia and fever
    5. Massive Envenomation
      1. Rhabdomyolysis
      2. Multiorgan failure (renal, hepatic)
      3. Hemolysis
      4. Seizures
      5. Pancreatitis
  7. Complications (rare - case reports)
    1. Vasculitis
    2. Nephritis
    3. Neuritis
    4. Encephalitis
    5. Myocarditis
    6. Guillain-Barre Syndrome
  8. Differential Diagnosis
    1. See Insect Bite
  9. Management: Reaction
    1. General measures
      1. Remove Stingers still embedded in skin (avoids foreign body reaction)
        1. Use a card or dull blade to scrape over the sting site to dislodge the Stinger
        2. Avoid squeezing the Stinger (injects more venom)
      2. Tetanus Vaccination is not needed for Hymenoptera Stings
    2. Systemic Allergic Reaction or Anaphylaxis Management
      1. See Anaphylaxis for management
      2. See Allergic Reaction
      3. Obtain history of prior Allergic Reaction history
      4. Obtain details of attack
        1. Location
        2. Number of stings
        3. Which type of Stinging Insect
      5. Recurrent systemic reaction in 50% of cases from future Hymenoptera Sting
        1. Reaction is specific to the 3 types: Bees, Fire Ants or Vespidae (wasps, hornets, yellow jackets)
        2. Systemic reaction risk is reduced to 3% risk with Desensitization
        3. Severe reaction is highest risk in small children, elderly or multiple stings
    3. Local Reaction
      1. Ice Packs or cool compresses
      2. Analgesics (e.g. NSAIDs, Acetaminophen)
      3. Unproved efficacy of:
        1. Antihistamines (e.g. Zyrtec)
        2. Topical Corticosteroids
        3. Topical papain (meat tenderizer) or baking soda
    4. Large Local Reaction
      1. Differentiate from Cellulitis and other vector borne conditions (e.g. Erythema Migrans)
      2. Prednisone or Methylprednisolone 1 to 2 mg/kg (children) up to 40 to 60 mg (adults) for 3 o 5 days
    5. Delayed Hypersensitivity or Serum Sickness
      1. Supportive care
      2. Systemic Corticosteroids
      3. Antihistamines
  10. Prevention
    1. See Stinging Insect Immunotherapy
    2. General
      1. Avoid floral print clothing
      2. Avoid floral fragrances
      3. Avoid walking barefoot
      4. Remove wasp and hornet nests when identified
      5. Cleanse outdoor garbage cans
      6. Clean eating areas of food remains
      7. Close food sources
    3. Bees
      1. Avoid walking through flowers
      2. Avoid bananas around hives (similar scent to bee alarm pheromone)
      3. Carbon dioxide and human sweat can also antagonize bees
    4. Fire Ants
      1. Inspect playgrounds and yards for ant mounds
      2. Toxic bait may target queen ant
  11. References
    1. Cowling and Ferreri (2019) Crit Dec Emerg Med 33(2): 17-25
    2. Herness (2022) Am Fam Physician 106(2): 137-47 [PubMed]
    3. Kemp (1998) J Postgrad Med 103(6):88-106 [PubMed]

Bees (C0004923)

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
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
Derived from the NIH UMLS (Unified Medical Language System)

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
Croatian Not Translated[Hymenoptera]
French Hymenoptera, Hyménoptères
Polish Błonkoskrzydłe, Błonkówki
Norwegian Hymenoptera
Portuguese Hymenoptera, Himenópteros
German Hymenoptera, Hautflügler
Italian Hymenoptera
Dutch Hymenoptera, Vliesvleugeligen
Derived from the NIH UMLS (Unified Medical Language System)

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
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
Derived from the NIH UMLS (Unified Medical Language System)

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)
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

Yellow jacket causing poisoning and toxic reactions (C0867896)

Concepts Injury or Poisoning (T037)
English Yellow jacket causing poisoning and toxic reactions
Derived from the NIH UMLS (Unified Medical Language System)

Hymenoptera sting (C1274548)

Concepts Injury or Poisoning (T037)
SnomedCT 403142004
English Hymenoptera sting (disorder), Hymenoptera sting
Spanish picadura de himenópteros (trastorno), picadura de himenópteros
Derived from the NIH UMLS (Unified Medical Language System)

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