Linfagitis superficial reactiva a insecto: un camino por la vía linfática / Insect-reactive superficial lymphangitis: a walk through the lymphatic pathwa

La linfangitis superficial aguda reactiva a picadura de insecto es una entidad poco descrita en la literatura. Se caracteriza por una inflamación de los conductos linfáticos debido a las toxinas inoculadas por el insecto. Se presenta como una lesión eritematosa ovalada en la zona de la picadura, que se extiende de manera lineal siguiendo el trayecto de un vaso linfático. El diagnóstico es clínico y el tratamiento sintomático. Es importante descartar la etiología infecciosa que puede confundirse con esta patología y cursar con elevada gravedad. Presentamos el caso de una paciente de 69 años, sin antecedentes personales de interés ni alergias conocidas, que acude a consulta por una lesión eritematosa, lineal y pruriginosa que por la anamnesis y la exploración podría ser una linfangitis aguda reactiva a insecto.(AU)

Acute superficial lymphangitis after insect bite is an entity little reported in the literature. This is characterized by an inflammation of the lymphatic ducts due to toxins inoculated by the insect. It presents as an oval erythematous lesion in the bite area, which extends in a linear manner along the path of a lymphatic vessel. Diagnosis is clinical and treatment is symptomatic. It is important to rule out the infectious etiology that can be confused with this pathology and be very serious. We report the case of a 69-year-old patient with no relevant personal history of interest or known allergies, who came to the clinic with an erythematous, linear and pruritic lesion that, based on the history and examination, could correspond to acute insect-reactive lymphangitis.(AU)

Social wasps in Spain: the who and where

Objective The objective of this study was to list the social vespids occurring in Spain, determine their presence in each region, and correlate the data with the vespids responsible for allergic reactions and their progression over time.Methods Insects distribution data were collected in two phases: from the southern half of Spain (2008–2012), and from the northern half of Spain (2016–2019). Data for the vespids were collected from the prescriptions of Hymenoptera venom immunotherapy (HVIT) at six Spanish hospitals in the years 2009 and 2019.Results Polistes dominula and Vespula germanica were the most widely distributed species. Vespa velutina was found to be present in a large part of northern Spain. During the 10 year period, the prescriptions of vespid VIT increased by 42.63%. The north of Spain saw a 3.61 fold greater predominance of prescriptions for Vespula (to some extent influenced by Vespa velutina allergy) whereas in central and southern Spain, there was a 3.97 fold greater predominance of prescriptions for Polistes.Conclusions It is the first study that compares the vespid distribution maps with VIT prescription. A noteworthy finding is the wide presence of Polistes dominula and Vespula germanica in Spain and the appearance of Vespa velutina allergy in the northern part of the country. Data of HVIT prescriptions reflect inter-regional variability with the predominance of Vespula (due to Vespula and Vespa) in the north and that of Polistes in the center and south of Spain (AU)

The Lights and the Shadows of Controlled Sting Challenge With Hymenoptera

Hymenoptera venom immunotherapy (VIT) is effective for protecting individuals with systemic allergic reactions caused by Hymenopterastings. The need for a tool that shows the degree of protection afforded by VIT and the lack of useful biomarkers have made the stingchallenge test (SCT) the gold standard for this disorder, although its use has both lights and shadows. SCT with Hymenoptera involvescausing a real sting in a patient diagnosed with allergy to the venom of the stinging insect and who is undergoing treatment with specificimmunotherapy. In Spain, SCT is included in the list of services offered by some hospitals and forms part of their daily clinical practice. Thisreview aims to analyze the strengths and weaknesses of this test and to describe the standardized procedure and necessary resources,based on the experience of a group of Spanish experts and a review of the literature. (AU)

La inmunoterapia con veneno de himenóptero (ITV) es un tratamiento que se ha mostrado eficaz en la protección de sujetos con reaccionesalérgicas sistémicas por picaduras de himenópteros. La necesidad de una herramienta que demuestre el grado de protección proporcionadapor la ITV, y la ausencia de biomarcadores útiles, convierte a la Prueba de Provocación con Repicadura (PPR) en el gold standard en estapatología, con sus luces y sus sombras. La PPR con himenópteros es una prueba que consiste en provocar una picadura real, a un pacienteque ha sido diagnosticado de alergia al veneno del insecto picador y habitualmente está en tratamiento con inmunoterapia específica.En España, la PPR se incluye en la cartera de servicios de algunos hospitales, formando parte de su práctica clínica habitual. Esta revisióntrata de analizar las fortalezas y debilidades de esta prueba, integrando el procedimiento estandarizado y recursos necesarios, basándoseen la experiencia de un grupo de expertos españoles y en la revisión de la literatura. (AU)

Api m 6 and Api m 10 as Major Allergens in Patients With Honeybee Venom Allergy

Background: Component-resolved diagnosis plays a key role in the diagnosis and treatment of honeybee venom allergy (HVA). Our aimwas to study whether any of the allergens not included in the usual diagnostic platforms are relevant in our population.Patients and Methods: The allergenic sensitization profile of Spanish patients who experienced a systemic reaction after a honeybee stingand were diagnosed with HVA was studied by immunoblotting based on raw autochthonous Apis mellifera venom characterized usingSDS-PAGE and mass spectrometry and a commercial assay (ImmunoCAP).Results: Allergens in the International Union of Immunological Societies database were detected in the raw A mellifera venom extract used,except Api m 12. Sera from 51 patients with a median (IQR) age of 46.2 years (35.6-54.6) were analyzed. ImmunoCAP revealed Api m 1and Api m 10 to be major allergens (88.2% and 74.5%, respectively). Moreover, Api m 6 (85.4%) was detected by immunoblotting.Conclusion: Api m 1, Api m 6, and Api m 10 are major A mellifera venom allergens in our population (AU)

Antecedentes: El diagnóstico molecular puede ser una herramienta valiosa en el diagnóstico y el tratamiento de la alergia al veneno deabeja. Este estudio investiga si alguno de los alérgenos no incluidos en las plataformas diagnósticas habituales son relevantes en nuestrapoblación.Pacientes y métodos: Estudiamos mediante immunoblotting el perfil de sensibilización alergénica en pacientes españoles diagnosticadosde alergia al veneno de abeja. Los resultados se compararon con los obtenidos usando un ensayo comercial (ImmunoCAP). El venenocrudo de Apis mellifera autóctona se obtuvo y caracterizó mediante SDS-PAGE y espectrometría de masas.Resultados: Los alérgenos descritos en la base de datos International Union of Immunological Societies (IUIS) fueron detectados enel extracto crudo de veneno de A. mellifera utilizado. Se analizaron sueros de 51 pacientes con una edad media de 46,2 años (rangointercuartil 35,6–54,6). Api m 1 y Api m 10 fueron detectados como alérgenos mayoritarios (88,2% y 74,5%, respectivamente) usandoImmunoCAP. Además, se encontró Api m 6 (85,4%) mediante immunoblotting.Conclusión: Nuestra población reconoce Api m 1, Api m 6 y Api m 10 como alérgenos mayoritarios del veneno de A. mellifera (AU)

Mosquito hypersensitivity may be associated with atopic background in children

Background Many children encounter unusual or “exaggerated” reactions such as large local, atypical or systemic reactions after mosquito bites. Objective The aim of this study was to document the clinical features of children with mosquito allergy and investigate the possible associations between demographic features and type of reactions in this population. Methods Children with large local or unusual reactions after mosquito bites who attended to our outpatient pediatric allergy department were enrolled in the study along with control subjects. Results A total of 180 children (94 with mosquito allergy and 86 age and sex-matched control subjects) with a median age of 6.8 years (IQR 5.5–9.3) were enrolled. Atopy (35.1% vs. 11.6%, p < 0.001) and grass pollen sensitization (28.7% vs. 8.1%, p < 0.001) were significantly more frequent in children with mosquito allergy. Skin prick test with mosquito allergen was positive in only 6 children (6,4%). Grass pollen sensitization was most common in children (28.7%) followed by sensitization to house dust mite (9.6%). 30 children (31.9%) had an accompanying atopic disease such as allergic rhinitis, asthma or atopic dermatitis. Bullae were significantly more frequent in children with asthma (41.7% vs.15.9, p = 0.034). The median duration of symptoms after onset were significantly longer in patients with ecchymosis, with immediate wheals and in children whose symptoms start in 20 min to 4 hours after mosquito bites. Conclusion There is an association between unusual, large local or exaggerated reactions after mosquito bites and allergic diseases in children. The severity of reactions increases with age and particularly in children with atopic background (AU)

Prevalence of atopic diseases in children with papular urticaria

BACKGROUND: Papular urticaria is a hypersensitivity reaction characterized by chronic and recurrent papular erythema. It occurs as a result of the bites of mosquitoes, fleas, bed bugs, and other insects; and it is generally seen in children. This study examines the prevalence of atopic diseases in patients with papular urticaria. METHODS: The medical records of 130 pediatric patients with the diagnosis of papular urticaria between August 2017 and August 2019, whose disease progression was followed in two ter­tiary care centers, were reviewed retrospectively. The patients were divided into two groups: under 5 and above 5 years old. The prevalence of the atopic disease in children with papular urticaria was compared with those in age-matched controls without papular urticaria. RESULTS: The study included 130 patients who were diagnosed with papular urticaria (64 males, 66 females, median age: 60 months). The prevalences of atopic disease, recurrent wheezing, and atopic dermatitis were higher in the group under 5 years old with papular urticaria than in the same-age control group (p = 0.001, 0.002, and 0.001, respectively). The prevalences of atopic disease, asthma, allergic rhinitis, and atopic dermatitis were higher in the group above 5 years old with papular urticaria than in the same-age control group (p = 0.001, 0.001, 0.001, and 0.007, respectively). CONCLUSIONS: Many children with papular urticaria are atopic children. These patients should be assessed not only in terms of papular urticaria but also in terms of comorbid atopic diseases

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Anaphylaxis to Vespa velutina nigrithorax: Pattern of Sensitization for an Emerging Problem in Western Countries

Objective: To define the sensitization pattern of patients with anaphylaxis to Vespa velutina nigrithorax (VVN). Methods: We studied 100 consecutive Spanish patients with anaphylaxis to Hymenoptera venom and systematically determined specific IgE (sIgE) to whole venoms (Vespula species, Polistes dominula, Apis mellifera, Vespa crabro, and Dolichovespula maculata) and their molecular components (rApi m 1, rApi m 5, rApi m 10, rVes v 1, rVes v 5, rPol d 5, and cross-reactive carbohydrates). Specific IgE to VVN venom and its antigen 5 (nVesp v 5) were measured in a subsample. Results: Seventy-seven patients had anaphylaxis to VVN. Of these, only 16 (20.8%) reported previous VVN stings, but were stung by other Hymenoptera. Positive sIgE (>0.35 kUA/L) to each of the whole venoms was detected in >70% of patients (Vespula species in 100%). The components showing >50% positivity were rApi m 5 (51.4%), rPol d 5 (80.0%), and rVes v 5 (98.7%). This pattern was similar to that of Vespula species anaphylaxis (n=11) but different from that of A mellifera anaphylaxis (n=10). Specific IgE to nVesp v 5 was positive in all patients (n=15) with VVN anaphylaxis and was correlated with sIgE to both rVes v 5 (R=0.931) and rPol d 5 (R=0.887). Conclusions: VVN has become the commonest cause of Hymenoptera anaphylaxis in our area. Most cases report no previous VVN stings. Their sensitization pattern is similar to that of patients with anaphylaxis to other Vespidae. Specific IgE to antigen-5 from VVN, Vespula species, and P dominula are strongly correlated in patients with VVN anaphylaxis (AU)

Venom allergy and knowledge about anaphylaxis among beekeepers and their families

BACKGROUND: Beekeepers and their families are at an increased risk of life-threatening anaphylaxis due to recurrent bee-sting exposures. OBJECTIVE: The aim of this study is to evaluate the demographic features, previous history of anaphylaxis among beekeepers and their family members, and their knowledge about the symptoms and management of anaphylaxis. METHODS: A standardized questionnaire was administered to beekeepers during the 6th International Beekeeping and Pine Honey Congress held in 2018, in Mugla, Turkey. Additionally, food-service staff from restaurants were surveyed as an occupational control group about their knowledge about anaphylaxis. RESULTS: Sixty-nine beekeepers (82.6% male, mean age 48.4 ± 12.0 years) and 52 restaurant staff (46.2% male, mean age 40.5±10.0 years) completed the questionnaire. Awareness of the terms 'anaphylaxis' and 'epinephrine auto-injector' among the beekeepers were 55.1% and 30.4% and among the restaurant staff were 23.1% and 3.8%, respectively. Of the beekeepers, 74% were able to identify the potential symptoms of anaphylaxis among the given choices; 2.9% and 5.8% reported anaphylaxis related to bee-stings in themselves and in their family members, respectively. None of the restaurant staff had experienced or encountered anaphylaxis before but 3.8% of their family members had anaphylaxis and those reactions were induced by drugs. CONCLUSION: It is essential that implementation of focused training programs about anaphylaxis symptoms and signs as well as practical instructions of when and how to use an epinephrine auto-injector will decrease preventable morbidities and mortalities due to bee-stings in this selected high-risk population of beekeepers and their family members, as well as other fieldworkers under risk

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Hymenoptera venom allergy among children in Italy: time for pediatricians to take action

Hymenoptera venom allergy (HVA) is one of the most frequent causes of anaphylaxis following a bee, vespid or ant sting. Real-life data regarding the management of HVA in children are lacking. To address this unmet need, we carried out a survey defining the current management of HVA in children among pediatric allergists in Italy. Educational investments on the improvement of the management of pediatric patients with HVA are urgently needed, and our analysis represents a relevant instrument in targeting a roadmap with this aim. The time for pediatric allergists to take action has come, and a task force from the Rare Allergic Diseases Commission of the Italian Society of Pediatric Allergy and Immunology is working on the topic to improve pediatricians' knowledge and optimize the care of these patients

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Respuesta al comentario del Dr. Galán / No disponible

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Artropatía del apicultor / Beekeeper' arthropathy

En los apicultores se ha descrito una artropatía inflamatoria de etiología desconocida pero relacionada con su actividad profesional. Se expone el caso de un apicultor que tras la picadura de abeja presentó una artritis de la articulación interfalángica del primer dedo de la mano izquierda. Aunque el curso clínico subagudo y los hallazgos de la RMN obligaban a plantear el diagnóstico diferencial con un proceso infeccioso, el resto de pruebas analíticas, de imagen y la evolución, junto al antecedente de episodio similar unos años antes en un dedo de otra mano tras la picadura de abeja, permitió el diagnóstico de esta entidad

An acute inflammatory arthritis of unknown cause has been described in beekeepers in relation to their work with the hives. We present the case of a beekeeper who, after a bee sting, developed arthritis of the interphalangeal joint of the first finger of his left hand. Although the subacute clinical course and the magnetic resonance imaging findings required the differential diagnosis with an infectious process, the rest of the laboratory tests. other imaging studies and the course, together with a history of a similar episode a few years earlier on a finger of the other hand after a bee sting, enabled us to diagnosis this condition

The method for selecting basophils might be determinant in the basophil activation test in patients with mastocytosis

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Successful adaptation of bee venom ommunotherapy in a patient monosensitized to api m 10

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Leishmaniasis mucocutánea labial, las apariencias pueden engañar / Mucocutaneous lip leishmaniasis, a diagnonstic challenge

La leishmaniasis es una infección endémica en nuestro medio. Dentro de sus presentaciones, la forma mucocutánea es la menos frecuente. A pesar de ello se ha de tener en cuenta incluso en casos clínicamente sugestivos de patología tumoral, como el que presentamos

Leishmaniasis is an endemic disease in the mediterranean region. Although mucocutaneous presentation is not frequent, we should considerate it in the differential diagnosis of tumoral pathology

Fascitis necrosante periorbitaria secundaria a rascado / Periorbital necrotising fasciitis secondary to scratching

Mujer de 80 años sin antecedentes médicos que consulta por empeoramiento de picor y dolor palpebral derecho tras la picadura de un insecto. Presenta zonas de laceración por rascado en los párpados, que evolucionan a placas de necrosis fibrinoide durante las primeras 24 horas. Se cultivan las lesiones, demostrando Streptococcus pyogenes y Staphylococcus aureus. Se ingresa a la paciente con diagnóstico de fascitis necrosante periorbitaria para tratamiento intravenoso con ceftriaxona, linezolid y desbridamiento quirúrgico urgente. Permanece ingresada durante 17 días; se le realizan curas diarias consistentes en desbridamiento de restos necróticos, limpieza con clorhexidina y curas con pomadas de mupirocina, sulfadiazina y miconazol. Sufre síndrome de shock tóxico estreptocócico, del que se recupera durante la primera semana de ingreso. A las 2 semanas se le realiza reconstrucción plapebral con autoinjerto de piel de espesor total preauricular en el párpado superior y avance malar lateral en el párpado inferior, con adecuado resultado cosmético y funcional

An 80 year-old woman with no relevant medical history, consulted for worsening of right palpebral itching and pain after an insect bite. Her eyelids had areas of laceration due to scratching, which rapidly progressed to fibrinoid necrosis over the first 24 hours. Lesions were cultivated, revealing Streptococcus pyogenes and Staphylococcus aureus. The patient was admitted to hospital with the diagnosis of periorbital necrotising fasciitis, in order to receive treatment with intravenous ceftriaxone, linezolid, and immediate surgical debridement. She remained in hospital for 17 days. Daily wound management consisted of debridement of necrotic remains, disinfection with chlorhexidine, and wound dressing with mupirocin, sulfadiazine, and miconazole ointments. The patient suffered streptococcal toxic shock syndrome, but she recovered over the first week. Palpebral reconstruction was performed on day 15, consisting of a preauricular total thickness skin graft for the superior eyelid, and lateral malar advancement to cover the lower eyelid. Adequate cosmetic and functional results were obtained

Eritema tubular tras picadura de insecto / Tubular erythem after insect bite

La linfangitis aguda es la inflamación de los conductos linfáticos, y la etiología infecciosa es la más frecuente en la edad pediátrica. Se presentan dos casos clínicos de linfangitis tubular aguda, ambos con una lesión inicial por la picadura de un insecto

Acute lymphangitis is the inflammation of lymphatic channels. Usually, in pediatrics, it is due to an infec-tious cause. We present 2 cases of acute tubular lymphangitis, both initiated after an insect bite

Usefulness of omalizumab and sting challenge test in hymenoptera venom allergy and mastocytosis

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