title: Insect anaphylaxis: addressing clinical challenges.
abstract: OBJECTIVE
  Few allergic reactions are as potentially life-threatening, or frightening to the patient, as anaphylaxis. Food, medications, and insect stings are the three most common triggers of anaphylaxis, but insect allergy provides the best opportunity to understand the biology of anaphylaxis. If the physician can establish a diagnosis of insect allergy, treatment with nearly 98% effectiveness can be initiated. However, sometimes patients have a compelling history of insect sting anaphylaxis, but negative skin and blood tests. This situation presents us with a fascinating opportunity to understand the biology of insect anaphylaxis.
  
  
  RESULTS
  Recent and ongoing work shows that occult mast cell disease may be critical in insect anaphylaxis. Mastocytosis, serum tryptase and basophil biology are key elements; genetic markers may potentially help us diagnose at-risk individuals and determine proper treatment. Understanding basophil activation may play an additional role both in diagnosis and knowing when therapy might be terminated.
  
  
  CONCLUSIONS
  Mast cell disease, serum tryptase and basophil biology are providing an opportunity to better understand and manage insect allergy. This evolving understanding should improve long-term management of insect anaphylaxis and help us to better understand the clinical dilemma of appropriate management of the history-positive patient in which testing is unable to detect venom-specific IgE. Furthermore, omalizumab's immunomodulatory effects may play a role in difficult-to-treat insect allergy and mastocytosis. Finally, unrelated to these, but still important as an ongoing risk factor, is the continued underutilization of epinephrine for both acute and long-term management of insect anaphylaxis.
authors.affiliation: Division of Allergy and Immunology and Allergy, Asthma & Immunology Associates, Omaha, Nebraska 68124, USA. jmtracy@cox.net
authors.forename: James M
authors.initials: JM
authors.lastname: Tracy
authors.forename: Elena J
authors.initials: EJ
authors.lastname: Lewis
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Demain
mesh_terms: D000707:Anaphylaxis / Q000175:diagnosis / Q000188:drug therapy / Q000209:etiology* / Q000276:immunology; D000818:Animals; D000888:Antibodies, Anti-Idiotypic / Q000627:therapeutic use; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized; D001180:Arthropod Venoms / Q000009:adverse effects / Q000276:immunology / Q000627:therapeutic use; D015549:Basophil Degranulation Test; D015415:Biomarkers; D003888:Desensitization, Immunologic; D004837:Epinephrine / Q000627:therapeutic use; D005786:Gene Expression Regulation; D020022:Genetic Predisposition to Disease; D006801:Humans; D006927:Hymenoptera; D007299:Insect Bites and Stings / Q000150:complications* / Q000276:immunology; D008407:Mast Cells / Q000276:immunology / Q000473:pathology; D008415:Mastocytosis / Q000097:blood / Q000150:complications / Q000175:diagnosis / Q000188:drug therapy / Q000235:genetics; D015337:Multicenter Studies as Topic; D009784:Occupational Diseases / Q000453:epidemiology / Q000209:etiology; D000069444:Omalizumab; D012307:Risk Factors; D012882:Skin Tests; D053802:Tryptases / Q000097:blood
chemical_list: D000888:Antibodies, Anti-Idiotypic; D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D001180:Arthropod Venoms; D015415:Biomarkers; D000069444:Omalizumab; D053802:Tryptases; D004837:Epinephrine