title: Anaphylaxis after hymenoptera sting: is it venom allergy, a clonal disorder, or both?
abstract: A 47-year-old man presented with loss of consciousness 5 minutes after being stung by a yellow jacket in his backyard. Epinephrine and fluids were required for resuscitation. Allergy evaluation revealed specific IgE to yellow jacket and honeybee, and the patient was started on venom immunotherapy. He had systemic reactions during buildup and a severe anaphylactic episode requiring 3 doses of intramuscular epinephrine at maintenance doses. Immunotherapy was discontinued. Serum tryptase level after 1 such episode was 29 ng/mL, with a baseline level of 25 ng/mL 4 weeks later. The physical examination was unremarkable including no skin lesions of cutaneous mastocytosis. Because of elevated baseline tryptase level, a bone marrow biopsy was performed, which revealed multifocal dense infiltrates of mast cells. A diagnosis of systemic mastocytosis was made. The patient was treated with omalizumab and was able to tolerate immunotherapy and is currently maintained on lifelong immunotherapy. He was restung in the field and has not had anaphylaxis.
authors: Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. Electronic address: mcastells@partners.org.
authors: Mariana C
authors: MC
authors: Castells
authors: Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Jason L
authors: JL
authors: Hornick
authors: Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
authors: Cem
authors: C
authors: Akin
mesh_terms: D000707:Anaphylaxis / Q000097:blood / Q000175:diagnosis / Q000276:immunology*; D000818:Animals; D018926:Anti-Allergic Agents / Q000627:therapeutic use; D015415:Biomarkers / Q000097:blood; D001706:Biopsy; D001856:Bone Marrow Examination; D003131:Combined Modality Therapy; D003888:Desensitization, Immunologic / Q000379:methods; D004837:Epinephrine / Q000627:therapeutic use; D005440:Fluid Therapy; D006801:Humans; D007073:Immunoglobulin E / Q000097:blood; D007299:Insect Bites and Stings / Q000097:blood / Q000175:diagnosis / Q000276:immunology* / Q000628:therapy; D008297:Male; D034721:Mastocytosis, Systemic / Q000097:blood / Q000175:diagnosis / Q000276:immunology* / Q000628:therapy; D008875:Middle Aged; D000069444:Omalizumab / Q000627:therapeutic use; D011237:Predictive Value of Tests; D016896:Treatment Outcome; D053802:Tryptases / Q000097:blood; D014862:Wasp Venoms / Q000009:adverse effects / Q000276:immunology* / Q000627:therapeutic use; D014863:Wasps / Q000276:immunology*
chemical_list: D018926:Anti-Allergic Agents; D015415:Biomarkers; D014862:Wasp Venoms; D000069444:Omalizumab; D007073:Immunoglobulin E; D053802:Tryptases; D004837:Epinephrine
keywords: Hymenoptera; Mast cells; Mastocytosis; c-kit mutations