Gretchen W.

Cook
Courtesy of Vespa Laboratories, Inc.

Yikes! It’s a bee, or maybe a wasp, heading right in your direction. Almost
everyone momentarily cringes when a flying, stinging insect zooms near.
The reaction is justified. Bee stings hurt! For some people, however, an
insect sting can mean more than discomfort: it can be life-threatening.
Businessman and golfer O. B. Beckham of Lake Oswego, Ore, is one
person for whom a bee sting was life-threatening. It happened on a golf
course.
“It was late on a Saturday evening, and I was out playing golf by
myself,” says Beckham. “A bee stung me right on the cheek. Fortunately
there was a foursome ahead of me. They saw something had happened
and asked, ‘Can we help you?’ Being a typical male, I said ‘No, I’m fine.’
They could tell something was wrong, though. I finally agreed to be
helped, and they got me into their golf cart. I blacked out almost immedi-
ately. I was told that, when I was taken to the clubhouse, I had no pulse
and had stopped breathing.”

Luckily for Beckham, lifeguards at a nearby
pool knew CPR, and paramedics were on the
scene within three minutes. What Beckham
experienced is anaphylaxis, or anaphylactic
shock. This is a very serious systemic reaction
to an allergen, most often caused by exposure
to a food, insect sting, or medication. If
untreated, this type of systemic allergic reac-
tion can lead to death. Approximately 50 peo-
ple die from stinging insects each year in the
US. While this number may not seem signifi-
cant, it points to a much more alarming fig-
ure. There are hundreds more who have near-
death experiences and thousands who have
reactions and may be candidates for a full-
blown anaphylactic reaction.
“From epidemiologic studies, we have data
suggesting that 1 to 2 percent of the popula-
tion have, in fact, experienced a real systemic
allergic reaction,” says Miles Guralnick,
President and CEO of Vespa Laboratories
Inc., a company that manufactures venom for
bee immunotherapy (bee venom shots).
Guralnick is an entomologist who has spent

22
| ASTHMA MAGAZINE May/June 2003
more than two decades studying
stinging insects and their venom.
“These studies tell us that there are a
lot of people out there for whom an
insect sting could be a serious health
threat.”
Not All Reactions Are
the Same
In order to make an informed
decision about seeking medical eval-
uation for an insect sting, it is
important to understand the various
types of reactions. There are three
types of reactions to insect stings.
Local Reactions
“Everyone who gets stung will
have a local reaction,” says
Guralnick. “It’s going to hurt a lot,
and it’s going to turn red around the
sting site. Typically, there will be a
hive, or a weal and flare. The pain
will go away after some time, and
then there will be some itching for
maybe three to seven days. The site
may be warm to the touch. This is a
normal, local reaction.”
Large Local Reactions
In a large local reaction, the
swelling can be quite extraordinary
and can last an alarming amount of
time. “A large local reaction can last
for three or four days,” says
Guralnick. “The swelling is contigu-
ous with the sting—this means that
it is connected to the place where the
sting was. And these reactions can
cause swelling that spreads beyond
more than one joint. For example,
you can get stung on the hand and
you can swell all the way up to the
elbow. These swellings can be very
uncomfortable, even debilitating—
where the person may not be able to
go to work.”
Large local reactions are typically
treated with ice, antihistamines, and,
occasionally, systemic steroids.
Despite the impressive size of the
reaction, it is not considered a true
allergic emergency. However, anyone
experiencing such a reaction should
discuss it with a doctor.
One note
of caution: a
large local
reaction
occurring on
the body near
the airways
can cause
asphyxiation
when swelling
narrows an air
passage.
“People who
get stung near
an airway
should seek immediate medical care
regardless of allergy,” says Guralnick.
“A sting on the mouth, nose, or neck
can close an airway—and it can hap-
pen quickly.”
Systemic Allergic Reactions
The third type of reaction is a sys-
temic reaction, and it is a true aller-
gic emergency. “In this case, the
patient has symptoms distant from
the sting site in addition to the nor-
mal local sting site reactions I’ve
described,” says Guralnick. “The
other symptoms can involve the four
different systems of the body—the
skin, the respiratory system, the gas-
trointestinal system, and the vascular
system.” In the event of a systemic
allergic reaction, it is imperative to
seek medical attention immediately.
Systemic Skin Reactions
Systemic skin reactions take place
in areas away from the sting site. “For
example, a person may get stung on
the hand, and then hives form all
over his body,” says Guralnick. “Or,
his eyes, lips, or entire face may swell
up. He may feel a thickening in the
tongue. These systemic allergic reac-
tions of the skin are dangerous.”
Systemic Respiratory Reactions
“A systemic reaction can also mani-
fest in the respiratory system,” says
Guralnick. “Some patients will get
stung on the hand and will find it
difficult to breathe—they’re short of
breath. Or the back of their throat
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starts to swell, and they feel like their
airway is closing down. These reac-
tions are also very serious.”
Systemic Gastrointestinal Reactions
Some patients experience nausea,
vomiting, or diarrhea as part of their
allergic reaction to an insect sting.
Systemic Vascular Reactions
“Probably the most profound
reactions are the vascular system
reactions where there can be a very
quick drop in blood pressure; people
become faint, dizzy, or nauseated,”
says Guralnick. “Sometimes they
pass out. This type of reaction can
proceed to fatality very quickly.”
Escalating Reactions
Evidence suggests that there may
be a “cumulative effect” with insect
stings—with reactions becoming
more severe with subsequent stings.
There is also some evidence that
stinging insect allergy may become
more severe with age.
This was the case for Beckham.
“Before my life-threatening reaction,
I had had a reaction a number of
years before. I was stung and my
arm was swollen. No one told me I
should be concerned about it, so I
said ‘I’ll just carry some Benadryl in
my golf bag.’ So that’s what I did,
and when I got stung again, I was
actually on the golf course.” (Note:
Benadryl cannot be relied upon to
treat such a reaction because the reac-
tion may develop very quickly.
| 23
 By reducing sensitivity to insect stings
with immunotherapy, a person should feel
less concerned about stings and better
able to enjoy the summers.
Benadryl takes 15 to 20 minutes to
take effect.)
Rescue Medications
The only true, life-saving medica-
tion in an allergic emergency is an
injectable drug called epinephrine. It
is available in an easy-to-use device
called an Epi-Pen that comes ready
with a premeasured dose. It is
designed so people can easily carry it
with them, and it is simple enough
to use that even children can self-
administer it.
If someone has a serious allergic
reaction, more than one epinephrine
injection may be needed to complete-
ly reverse the reaction. “The person
having a systemic allergic reaction still
needs to go to a hospital,” says
Guralnick. The bottom line is that,
given the serious nature of this aller-
gy, it is essential that emergency epi-
nephrine is readily available and that
a person seeks immediate emergency
medical care following a sting.
Good News:
Immunotherapy Works
When a person has experienced a
systemic allergic reaction to a sting,
the fear of future stings can hamper
24
| ASTHMA MAGAZINE May/June 2003
daily activities. “The
first thing I did was
cancel a camping
trip,” says Beckham.
“And I cut back on
playing golf.”
Beckham didn’t
stay sidelined for
long, however; he dis-
covered bee venom
immunotherapy, also
known as “bee venom
shots.” Stinging
insect venom
immunotherapy is a
highly successful
treatment and is cov-
ered by most health
insurance plans.
These injections
expose a person to
increasing amounts of
venom over a long
period of time, allowing the body
to build a tolerance to it.
“There are five types of insect
stings you worry about,” says
Beekham. “I wound up being allergic
to all five. I started off taking weekly
allergy shots. I only go for shots once
a month now. About every eighteen
months or so I am retested [to deter-
mine tolerance to bee venom].”
For a person who is not sure
whether or not a bee sting could
cause a severe allergic reaction, an
allergist is best able to make this
diagnostic evaluation. The evaluation
typically begins with a detailed histo-
ry of previous stings and any reac-
tions. If a history exists to suggest a
possible allergy, skin tests should be
conducted. If a person has a positive
history and a positive diagnostic test,
that person should be considered a
candidate for immunotherapy.
“Immunotherapy starts out at
very, very, very small doses,” says
Guralnick. “The shots are usually
given once a week for a period of
time. Gradually the doses of venom
increase until a patient is up to what
is called a maintenance dose. This
usually takes several months. At that
point the person will typically
receive the maintenance injection at
4- to 6-week intervals.” At mainte-
nance level, the patient is no longer
considered sensitive to stings.
(Doctors recommend that patients
undergoing immunotherapy, even
when at maintenance levels, still
carry an Epi-Pen as a precaution
during bee season.)
It is open to some debate as to
how long one must continue
immunotherapy. Some doctors
believe that it must be continued
indefinitely, particularly in patients
who have suffered severe, life-threat-
ening reactions. However, according
to recent research, immunotherapy
can cause permanent loss of venom
allergy in patients, which is main-
tained even after the immunotherapy
is stopped. The treatment must be
maintained for years, but how many
years must be determined by an
allergist on a case-by-case basis.
Getting Summers Back
Immunotherapy creates a physical
change in the way the body reacts to
a bee sting. However, just as impor-
tant, it can cause an emotional
change that may have a huge impact
on a person’s quality of life. “People
who [previously] felt unable to go
out in the summer feel they have
gotten their summers back,” says
Guralnick.
“Do I still notice bees? You bet,”
says Beckham. “But they don’t both-
er me. You never know when you’re
going to get stung. Who can predict
what a bee or a yellow jacket will do?
But you know when you get the
shots you build up a resistance to
stings, so it really takes the fear out
of things.”
Gretchen W. Cook is a freelance writer
in Jackson, Mississippi, who specializes
in family and health topics. She was
diagnosed with asthma at age 6.
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doi:10.1067/mas.2003.31