A 31-year-old farmer is hospitalized with a severe reaction to a bee (Hymenoptera) sting. He developed respiratory distress requiring endotracheal intubation in the field. He was treated with epinephrine and corticosteroids with rapid recovery. The patient has no prior similar incidents and no allergies. He is given an epinephrine autoinjector and instructed on its use.
Which of the following is the most important part of discharge planning in this patient?

Question

A 31-year-old farmer is hospitalized with a severe reaction to a bee (Hymenoptera) sting.  He developed respiratory distress requiring endotracheal intubation in the field.  He was treated with epinephrine and corticosteroids with rapid recovery.  The patient has no prior similar incidents and no allergies.  He is given an epinephrine autoinjector and instructed on its use.
Which of the following is the most important part of discharge planning in this patient?

Quizplus · Accepted Answer

Hymenoptera stings can cause life-threatening anaphylaxis. One study found that up to 50% of patients with anaphylaxis had no previous reaction or known allergy. Sixty percent of adult subjects with a history of anaphylaxis from a previous sting will have anaphylaxis with a repeat sting. Venom immunotherapy (VIT) reduces this risk to less than 5% by producing venom-specific immunoglobulin (Ig) G, changing T cell responses, and decreasing venom-specific IgE. VIT is indicated in patients with a history of systemic allergic reaction to an insect sting and evidence of venom-specific IgE, either by skin or in vitro test. Discharge care should also include education on avoidance and an epinephrine autoinjector. (Choices A and B) Acute medical treatment for anaphylaxis includes intramuscular epinephrine, H-1 receptor antagonists, corticosteroids, and supportive therapy for shock. However, these agents are not as beneficial after resolution of the acute episode. (Choice D) Serum IgE levels rise during the acute anaphylaxis stage and during the first few months of immunotherapy before decreasing over the next 3-5 years of VIT. However, these levels do not reliably predict protection from future anaphylaxis reactions. (Choice E) Tryptase is a mediator released from mast cells and basophils. Serum tryptase levels may be elevated in anaphylaxis but also in other mast cell disorders (eg, systemic mastocytosis) and myelodysplastic syndromes. In addition, tryptase decreases after the anaphylaxis reaction and would not be as useful to monitor as immunotherapy in this patient. Educational objective: Venom immunotherapy reduces the risk of anaphylaxis recurrence from 60% to 5%. It is indicated for patients with history of systemic reaction to an insect sting and venom-specific immunoglobulin E. __________ References: Chapter 4: Stinging insect allergy and venom immunotherapy. (http://www.ncbi.nlm.nih.gov/pubmed/22794677) A controlled trial of immunotherapy in insect hypersensitivity (http://www.ncbi.nlm.nih.gov/pubmed/78446)

A 31-Year-Old Farmer Is Hospitalized with a Severe Reaction to a Bee