a) Manifestations include edema, fatigue, vomiting, diarrhea, headache, hyporeflexia, slurred speech, hypertension, tachycardia, hypotension, seizures, coma, rhabdomyolysis, and acute renal failure.
b) Delayed toxic reactions are rare, but do occur. Such patients are asymptomatic after a massive bee envenomation, with normal initial laboratory results, but later develop laboratory evidence of hemolysis, coagulopathy, thrombocytopenia, rhabdomyolysis, liver dysfunction, and disseminated intravascular coagulation.

a) LOCAL: The pain of a Hymenoptera sting and extensive local swelling, often exceeding 10 cm, may persist for several days. Large local reactions do not predict progression to systemic reactions. The risk of eventual anaphylaxis in such individuals is only 5% to 10%, despite the presence of venom-specific IgE.
b) SYSTEMIC: The systemic allergic reactions that may occur within 30 minutes of a sting include cutaneous (generalized urticaria, erythema, pruritus, and angioedema), respiratory (edema of the tongue, epiglottis, and larynx; bronchial constriction causing dyspnea, stridor, dysphagia, or wheezing), and/or vascular symptoms (cardiovascular collapse, hypotension, and loss of consciousness). The cause of death is usually respiratory obstruction, cardiovascular collapse, or both.

a) Corneal edema, ulceration, hyperemia, pain, scarring, linear keratitis, and secondary bacterial keratitis can occur (Chinwattanakul et al, 2006; Arcieri et al, 2002; Miyashita, 1992; Chen & Richardson, 1986; Meija et al, 1986; Smolin & Wong, 1981)

a) Pain, swelling, tearing, hyperemia, conjunctival chemosis can occur (Miyashita, 1992; Smolin & Wong, 1981).

a) Heterochromia-iridis, internal ophthalmoplegia, punctate subcapsular opacities (Chinwattanakul et al, 2006; Song & Wray, 1991; Singh, 1984) ; retrobulbar neuritis (Goldstein et al, 1960); optic neuritis; degeneration of retinal ganglion rarely occur.
b) OCULAR TRAUMA
c) BLINDNESS
d) OPHTHALMOPARESIS

a) Cardiac arrhythmias and myocardial infarction following Hymenoptera stings are rare and are usually associated with the anaphylactic response. They are primarily associated with stings in older patients with preexisting heart disease (Muller et al, 1989; Jones & Joy, 1988; Levine, 1976) but also may develop in young adults (Freye & Ehrlich, 1989).
b) CASE REPORT: A 69-year-old man with minimal cardiac risk factors developed second-degree heart block, mild hypotension (92/40), respiratory failure, and an ST elevation myocardial infarction demonstrated on ECG after a bee sting. He was not treated with epinephrine. The patient was initially intubated and taken to the catheterization lab, which revealed minimal coronary artery disease with no acute structural lesions found. A complete recovery was made 3 days later (Valkanas et al, 2007).
c) CASE REPORT: A 58-year-old man developed anaphylaxis with dizziness, chest pain, flushing, diaphoresis, and erythema minutes after a wasp sting to the left elbow. EMS arrived and found the patient hypotensive (86/54 mm Hg), with ECG showing ST elevation; inferior STEMI was diagnosed. Aspirin, clopidogrel, diphenhydramine, and methylprednisone were administered, but no epinephrine was given. The patient was taken to the catheterization lab on arrival and normal coronary arteries were found. The patient made a rapid recovery and was discharged the following day (Rekik et al, 2009).
d) Cardiorespiratory arrest has been reported after multiple stings from Africanized honey bees (Franca et al, 1994).

a) CASE REPORT: A 19-year-old patient developed severe myocardial depression and pulmonary edema associated with anaphylaxis from a sting (Otero et al, 1991).

a) Hypertension has occurred in children with multiple bee stings (Franca et al, 1994; Meszaros, 1990) and in an adult with multiple wasp stings (Chen et al, 2004).

a) Hypotension has developed several days after multiple Africanized honey bee stings, which resulted in death (Franca et al, 1994).
b) A 30-year-old man developed persistent hypotension (average blood pressure 80/40 mm Hg), unresponsive to administration of dopamine and IV fluids, after receiving more than 2000 Africanized honeybee stings (Diaz-Sanchez et al, 1998).

a) Tachycardia has been reported following multiple Africanized honeybee stings (Betten et al, 2006; Diaz-Sanchez et al, 1998; Franca et al, 1994).

a) GIANT CELL ARTERITIS: A 71-year-old man stung by Hymenoptera on the knee developed progressively worse bilateral orbital pain, which later localized over the left temporal artery. Histologic samples showed thickening of the arterial wall with infiltration of lymphocytes and histiocytes. Serum IgE levels were elevated (713 Units/mL) and IgE specific for yellow jacket was extremely high. Symptoms improved with prednisone therapy (Schoen, 1998).

a) CASE REPORT: A 71-year-old woman was stung by a swarm of wasps. She developed right-sided facial weakness and left-sided limb weakness 24 hours later and then developed paraplegia. On examination, she had cold legs with decreased dorsalis pedis pulses and hyporeflexia of the legs. D-dimer level was elevated at 1151 ng/dL (normal < 500 ng/dL), as were fibrinogen degradation products of 4 mcg/mL (normal <1 mcg/mL). An arteriogram showed total occlusion of the infrarenal aorta without collateral circulation. Approximately 80 hours postenvenomation, the patient underwent an emergent thrombectomy (Chen et al, 2004).
b) CASE REPORT: A 40-year-old man developed a thrombus occluding the lower 3 arteries of the left leg after experiencing approximately 10 bee stings. The patient developed paresthesias in the affected limb the night after the event, and cyanosis appeared in the first and second left toes approximately 24 hours after presentation. Genetic testing revealed the patient had an undiagnosed anomaly that predisposed him to thrombosis (homozygous mutation in the methylenetetrahydrofolate reductase gene (A1298C) and heterozygous mutation in the prothrombin gene (G20210A)). The patient was treated with anticoagulant and antiplatelet therapy (warfarin and aspirin), and the thrombus resolved without further sequelae (El Husseiny et al, 2011).

a) Airway obstruction may occur (Anon, 1988; Jones & Joy, 1988; McLean, 1987; Butterton & Clawson-Simons, 1987).

a) Apnea, respiratory insufficiency, and/or cardiopulmonary arrest have been reported in patients who became comatose after receiving multiple stings (Watemberg et al, 1995; Franca et al, 1994) .

a) Dyspnea and tachypnea have been reported in patients with anaphylaxis and those receiving multiple stings (Betten et al, 2006; Speach et al, 1998; Franca et al, 1994; Otero et al, 1991) .

a) Coma has been reported in adults and children stung multiple times by Africanized honeybees (Iliev et al, 2010; Diaz-Sanchez et al, 1998; Franca et al, 1994) or hornets (Watemberg et al, 1995).

a) CASE REPORT: Tonic-clonic seizures developed in a 3-year-old approximately 6 hours after more than 40 hornet stings (Watemberg et al, 1995).

a) CASE REPORT: An initial effect in an adult was slurred speech 8 hours after being stung by hornets. His condition significantly deteriorated after 1 day, with the development of epidural and intracerebral hemorrhage and delayed peripheral neuropathy (Yao & Deng, 1994).

a) Depressed deep tendon reflexes were reported in a fatal pediatric case of multiple hornet stings (Watemberg et al, 1995).

a) Delayed neurologic hypersensitivity reactions which rarely occur, but can be fatal, include CNS demyelination (Means et al, 1973) and delayed peripheral neuropathy (van Antwerpen et al, 1988).
b) CASE REPORT: Headache, disorientation, and persistent memory loss occurred several days after anaphylaxis from a Hymenoptera sting (Mazza et al, 1991).
c) CASE REPORT: Epidural and intracranial hemorrhage about 1 day after exposure, followed by sensory and distal axonal neuropathy identified on day 26, developed in an adult who developed disseminated intravascular coagulation after being stung by hornets (Yao & Deng, 1994).

a) A temporary brachial plexus block occurred following a bee sting on the right side of the neck (Hay et al, 1992).
b) Two cases of temporary bilateral facial palsy have occurred as a result of Hymenoptera stings. One patient reported being stung on the thorax and the other on the arm (Raucq & Dupuis, 1998).
c) CASE REPORT: A 6-year-old girl developed local pain and swelling, and then a progressive, symmetrical, ascending weakness of her lower extremities within 3 days after a honey-bee sting on her left thigh. Serial nerve conduction studies confirmed a diagnosis of acute motor axonal neuropathy. Following treatment with IV immunoglobulin (2 g/kg over 2 days), her symptoms gradually improved. On a follow-up visit 20 weeks later, she continued to have muscle weakness. She was able to walk unassisted but could not run or climb stairs. She continued to have regular physiotherapy (Saini, 2014).

a) POST-STROKE HEMICHOREA: A 50-year-old man with multiple bee stings (3 bee stings on both of his proximal tibia areas) experienced itching and 2 episodes of syncope and received an oral H1 blocker from a local clinic. The next day, he presented to an ED with itching, dyspnea, and lip swelling. He was treated with IV methylprednisolone, chlorpheniramine, ranitidine, and IM epinephrine (0.3 mg). About 27 hours after the bee stings, he developed a sudden onset of involuntary hyperkinetic movement (hemichorea) of the left leg. Diffusion magnetic resonance imaging of the patient showed right temporal lobe infarction. A right M2 inferior and superior division branch occlusion was observed in a brain computed tomography angiography. All pathologic findings were normal. Following treatment with aspirin, citicoline sodium, lorazepam, and haloperidol, his involuntary movements resolved the day after admission (An et al, 2014).

a) CASE REPORT: A 71-year-old woman was stung multiple times by wasps and, 24 hours later, developed right-sided mouth deviation and numbness and weakness of her left-sided extremities progressing to paraplegia. Physical examination showed generalized muscle tenderness, left hemiplegia, paraplegia, absent bilateral extensor plantar reflexes, and hyporeflexia of the lower extremities. An initial brain CT scan was normal; however, a brain CT scan, approximately 2 weeks later, showed a right middle cerebral artery infarction. The patient gradually recovered with supportive care (Chen et al, 2004).
b) CASE REPORT: A 60-year-old man presented after being stung approximately 100 times on his face, head, and limbs. He was treated with antihistamines and subcutaneous epinephrine. Two hours after the incident, he developed left-sided hemiplegia and dysarthria. MRI showed ischemic changes in the frontal lobe, right temporoparietal area, and bilateral centrum semiovale. Aspirin, antiedema therapy, and low molecular weight heparin were given as treatment. At a follow-up 3 months later, the patient's dysarthria had resolved and slight left-sided hemiplegia remained (Temizoz et al, 2009).
c) CASE REPORT: A 50-year-old man with multiple bee stings (3 bee stings on both of his proximal tibia areas) experienced itching and 2 episodes of syncope and received an oral H1 blocker from a local clinic. The next day, he presented to an ED with itching, dyspnea, and lip swelling. He was treated with IV methylprednisolone, chlorpheniramine, ranitidine, and IM epinephrine (0.3 mg). About 27 hours after the bee stings, he developed a sudden onset of involuntary hyperkinetic movement (hemichorea) of the left leg. Diffusion magnetic resonance imaging of the patient showed right temporal lobe infarction. A right M2 inferior and superior division branch occlusion was observed in a brain computed tomography angiography. All pathologic findings were normal. Following treatment with aspirin, citicoline sodium, lorazepam, and haloperidol, his involuntary movements resolved the day after admission (An et al, 2014).

a) CASE REPORT: A 30-year-old man was stung by a bee and suffered cardiorespiratory arrest. Upon emerging from coma he presented with severe apraxia secondary to hypoxic brain injury (Speach et al, 1998).

a) Exacerbation of multiple sclerosis (MS) has been reported following wasp stings in a 41-year-old man. The authors speculated that a wasp sting in a nonallergic patient could raise serum levels of interferon gamma that might lead to a flare of MS symptoms (Dionne et al, 2000).

a) CASE REPORT: An 8-year-old boy developed cavernous sinus syndrome and bilateral cerebral infarcts secondary to a wasp sting on his right eyebrow and nasal bridge. The child presented to the hospital with significant swelling of the right eye and the inability to open the right eyelid. The child developed hemiplegia and altered senses 8 days after the sting and was unable to move his upper and lower limbs 1 day later. MRI and CT imaging revealed infarcts in the left frontoparietal cortex, suggestive of bilateral cavernous sinus thrombosis, posterior limb of the left internal capsule and right subcortical region. Right ophthalmiac exam revealed complete ophthalmoplegia with total ptosis and dilated and fixed pupils along with total absence of eye movements in all directions. Left ophthalmic examination showed corneal ulcer, partial ptosis, and a reduced range of eye movement, particularly in outward direction and sluggish papillary reaction. He also exhibited left upper motor neuron type facial nerve palsy. The child regained consciousness after 15 days of treatment with antibiotics (systemic and topical), anticoagulants, and antiinflammatory eye drops. On final exam, the patient was able to move the left upper and lower limbs, and his eye swelling and ptosis had reduced, but right-sided complete ophthalmoplegia remained (Vidhate et al, 2011).

a) CASE REPORT: A 10-year-old boy developed severe peripheral quadriparesis and sphincteric disorder (urinary incontinence) within 40 hours after being stung by a wasp. Following supportive care, including corticosteroid therapy (dexamethasone 1 mg/kg/day IV in 4 divided doses for 4 days and then gradual reduction of the dose for the next 10 days), his condition gradually improved in the next 72 hours. About 3 weeks later, he was discharged with a diagnosis of toxo-allergic polyradiculoneuropathy caused by wasp sting (Banovcin et al, 2009).

a) CASE REPORT: Nausea and multiple episodes of vomiting occurred in a 13-year-old boy approximately 8 hours after having been stung by approximately 700 honey bees (Betten et al, 2006).

a) Hepatic necrosis has been detected upon autopsy in fatal cases of multiple honeybee (Franca et al, 1994) and hornet stings (Watemberg et al, 1995). Shock and anoxia may have contributed to the hepatic effects.

a) Elevated liver function tests have occurred in patients with multiple bee (Betten et al, 2006; Diaz-Sanchez et al, 1998; Franca et al, 1994; Kini et al, 1994; Meszaros, 1990) , wasp (Chen et al, 2004), and hornet (Sakhuja et al, 1988) stings.

a) CASE REPORT: A 73-year-old woman with no known allergies was stung 518 times by a swarm of bees. One day later she was found unresponsive at home with massive soft tissue swelling, severe hypertension, and signs of pulmonary congestion. Despite supportive care, her condition deteriorated and she developed severe rhabdomyolysis, toxic hepatitis, and acute renal failure. Following further symptomatic therapy, including 7 sessions of hemodialysis, her condition gradually improved and she was discharged 20 days after presentation to the nephrology clinic. At this time, she developed hemorrhagic gastritis with melena and posthemorrhagic anemia, but was discharged 12 days later after her condition improved again. On a follow-up visit 6 months later, she had compensated polyarthrosis and hypertension (Iliev et al, 2010).

a) Acute renal failure has been associated with multiple Hymenoptera stings (eg, Africanized bees, yellow jackets, wasps); onset is within 24 to 48 hours of the sting (Iliev et al, 2010; Orletsky & Thomas, 2000b; Diaz-Sanchez et al, 1998; Deshmukh & Borse, 1996; Watemberg et al, 1995; Franca et al, 1994; Beccari et al, 1992; Munoz-Arizpe et al, 1992; Nace, 1992; Elgart, 1990; Sakhuja et al, 1988; Meija et al, 1986; Bousquet et al, 1984).
b) PATHOGENESIS: Intravascular hemolysis and/or rhabdomyolysis may have been responsible for nephrotoxicity in some of the above patients; however, a direct toxic effect of the venom on renal tubules in the absence of hemolysis or rhabdomyolysis has occurred (Beccari et al, 1992; Nace, 1992).
c) CASE REPORT: A 73-year-old woman with no known allergies was stung 518 times by a swarm of bees. One day later she was found unresponsive at home with massive soft tissue swelling, severe hypertension, and signs of pulmonary congestion. Despite supportive care, her condition deteriorated and she developed severe rhabdomyolysis, toxic hepatitis, and acute renal failure. Following further symptomatic therapy, including 7 sessions of hemodialysis, her condition gradually improved. After 20 days in an acute care hospital she was discharged to a nephrology clinic where she subsequently developed hemorrhagic gastritis with melena. She remained in this facility for 12 days and was discharged. On a follow-up visit 6 months later, she had compensated polyarthrosis and hypertension (Iliev et al, 2010).
d) CASE REPORT: A 13-year-old boy developed facial swelling, nausea, vomiting, tachycardia, fever, and hypotension approximately 8 to 12 hours after having been stung by approximately 700 bees. Laboratory studies revealed elevated serum creatinine (3.1 mg/dL), BUN (38 mg/dL), and creatine phosphokinase (32,520 ng/mL) levels. Urinalysis showed hematuria and proteinuria. During the initial 24 hours of monitoring, his urine output was minimal (approximately 300 mL), but improved with hydration and administration of diuretics. Forty-eight hours after envenomation, the patient's creatine phosphokinase level peaked at 106,720 ng/mL, but with continued supportive care, his rhabdomyolysis and associated renal insufficiency improved rapidly and he was discharged on hospital day 6 (approximately 7 days post-envenomation) (Betten et al, 2006).
e) CASE SERIES: Among 45 pediatric cases of wasp stings, 7 developed acute renal failure secondary to hemolysis and/or rhabdomyolysis. One patient died prior to therapy start due to hyperkalemia (K=8.7 mEq/L); the other cases recovered following peritoneal dialysis. All 6 surviving patients developed volume overload, 4 had hypertension, and 5 had oliguria for 9 to 15 days. Electrolyte imbalances (hyponatremia, hyperkalemia) and metabolic acidosis occurred in all patients. Peak serum creatinine levels ranged from 4 to 11.9 mg/dL, and dialysis was performed for 3 to 15 days (Vachvanichsanong & Dissaneewate, 2009).

a) Proteinuria has occurred in cases of multiple bee stings in children (Betten et al, 2006; Meszaros, 1990).

a) Hemolysis may occur following multiple hornet (Iliev et al, 2010; Sakhuja et al, 1988), Africanized honeybee (Franca et al, 1994; Munoz-Arizpe et al, 1992; Meija et al, 1986) , and yellow jacket (Bousquet et al, 1984) stings.
b) CASE REPORT: Disseminated intravascular hemolysis occurred in an adult following multiple hornet stings (Yao & Deng, 1994).

a) Thrombocytopenia has been reported following multiple bee (Munoz-Arizpe et al, 1992; Meszaros, 1990), hornet (Sakhuja et al, 1988), wasp (Chen et al, 2004), and Africanized honeybee stings (Orletsky & Thomas, 2000b).
b) Thrombocytopenia is thought to be due to a direct action of the Hymenoptera venom on platelets (Bousquet et al, 1984).

a) The normal reactions to a sting include localized pain, irritation, itching, redness, and swelling at the site of the sting; these effects often resolve within a few hours (Chen et al, 2004; Jerrard, 1996).
b) These effects are not IgE-mediated, but likely represent a response to toxic and inflammatory venom components such as vasoactive amines and peptides.
c) CASE REPORT: Diffuse pain and upper-body swelling, including the scalp, face, neck, chest, upper extremities, and abdomen, occurred in a 13-year-old boy 8 hours after having been stung by approximately 700 honeybees. With supportive care, the patient gradually improved and was discharged on hospital day 6 (approximately 7 days post envenomation) with minimal pain and significantly decreased facial and upper-body swelling (Betten et al, 2006).

a) Retention of a bee stinger for 4 months resulted in epidermal necrosis, marked pseudoepitheliomatous hyperplasia, and eosinophilic infiltration of the dermis (Hur et al, 1991).
b) CASE SERIES: A Japanese literature review evaluated 15 cases of multiple organ failure following multiple wasp (Vespa mandarinia) stings (17 to 100 stings). Thirteen of the 15 cases developed skin hemorrhage or necrosis prior to the development of organ failure, and the authors speculate a relationship may exist between the cutaneous hemorrhage or necrosis and predictive organ injury (Yanagawa et al, 2007).

a) Severe cutaneous infection and cellulitis have occurred after stings from yellow jackets and wasps, which may pick up virulent bacteria while foraging on decaying animal and vegetable matter (Yungingen, 1993) (Singh et al, 1992; Thiel, 1992).

a) CASE REPORT: An eosinophilic foreign-body granuloma and an IgE pseudolymphoma was accompanied by severe edema on the forehead of a man after receiving multiple bee stings to the area (Hermes et al, 1994).

a) Large local allergic reactions involve pain and extensive local swelling, which often exceeds 10 cm and may persist for several days (Jerrard, 1996a; Reisman & Livingston, 1992; Golden, 1987) .
b) Large local reactions do not predict progression to systemic reactions. The risk of eventual anaphylaxis in such individuals is only 5% to 10%, despite the presence of venom-specific IgE (Jerrard, 1996a; Li & Yunginger, 1992; Golden, 1987) .
c) A risk factor in the development of Hymenoptera venom allergy may be a short interval (less than 2 months) between the innocuous sting and the successive sting (Pucci et al, 1994).

a) CASE REPORT: A 35-year-old woman reported diffuse hair loss 4 months after a life-threatening encounter with multiple honeybee stings. The diagnosis of telogen effluvium was made (Sharma et al, 1997).

a) CASE REPORT: Diffuse pain and upper-body swelling, including the scalp, face, neck, chest, upper extremities, and abdomen, occurred in a 13-year-old boy 8 hours after having been stung by approximately 700 honey bees. With supportive care, the patient gradually improved and was discharged on hospital day 6 (approximately 7 days post envenomation) with minimal pain and significantly decreased facial and upper-body swelling (Betten et al, 2006).

a) Arthralgia often accompanies allergic serum sickness-type reactions and may have a delayed onset following Hymenoptera stings (Reisman & Livingston, 1989).

a) Rhabdomyolysis has been reported following multiple hornet, yellow jacket, and Africanized honeybee stings (Iliev et al, 2010; Vachvanichsanong & Dissaneewate, 2009; Orletsky & Thomas, 2000b; Franca et al, 1994; Sakhuja et al, 1988; Bousquet et al, 1984) .
b) CASE REPORT: A 73-year-old woman with no known allergies was stung 518 times by a swarm of bees. One day later she was found unresponsive at home with massive soft tissue swelling, severe hypertension, and signs of pulmonary congestion. Despite supportive care, her condition deteriorated and she developed severe rhabdomyolysis, toxic hepatitis, and acute renal failure. Following further symptomatic therapy, including 7 sessions of hemodialysis, her condition gradually improved and she was discharged 20 days after presentation to the nephrology clinic. At this time, she developed hemorrhagic gastritis with melena and posthemorrhagic anemia, but was discharged 12 days later after her condition improved again. On a follow-up visit 6 months later, she had compensated polyarthrosis and hypertension (Iliev et al, 2010).
c) CASE REPORT: A 13-year-old boy developed facial swelling, nausea, vomiting, tachycardia, fever, and hypotension approximately 8 to 12 hours after having been stung by approximately 700 bees. Laboratory studies showed elevated serum creatinine (3.1 mg/dL), BUN (38 mg/dL), and creatine phosphokinase (32,520 ng/mL) levels. During the initial 24 hours of monitoring, his urine output was minimal (approximately 300 mL), but improved with hydration and administration of diuretics. Forty-eight hours after envenomation, the patient's creatine phosphokinase level peaked at 106,720 ng/mL, but with continued supportive care, his rhabdomyolysis and associated renal insufficiency improved rapidly and he was discharged on hospital day 6 (approximately 7 days post envenomation) (Betten et al, 2006).

a) CASE REPORT: An infant developed arthritis with osteochondral destruction in a finger following bee stings. Bloody fluid was aspirated from the distal interphalangeal (DIP) joint shortly after the sting. The affected area was also treated with steroid ointment. Two years later, the DIP joint was still swollen, unstable, and tender, with slight deviation to the radial side. Radiography showed an osteolytic lesion in the distal-volar end of the middle phalanx and reduced joint space. Microscopy of a resected specimen, obtained surgically, showed fibrous granulation tissue with infiltration of inflammation cells, and without foreign bodies or epidermal tissues. Three years after the surgery, the bone defect had decreased, leaving an irregular subchondral bone surface and narrowing of the joint space (Haga et al, 2006).

a) Africanized bee venom caused widespread rhabdomyonecrosis in rats injected IM or IV with the venom (Azevedo-Marques et al, 1992).

a) SUMMARY (Li & Yunginger, 1992; Kaliner, 1984):
b) PATHOGENESIS: Histamine and tryptase play a primary role as a mediators of immediate hypersensitivity responses (Van der Linden et al, 1992).
c) ANAPHYLACTOID REACTION: Not all anaphylactic reactions are IgE-mediated. Some reactions are of the anaphylactoid type, which may involve the direct action of venom components such as mast cell degranulating peptides (Fricker et al, 1997; Lomnitzer et al, 1988). Anaphylactoid shock (not IgE mediated) following wasp stings has occurred in patients with systemic mastocytosis (Kors et al, 1993).
d) INCIDENCE OF ALLERGIC SENSITIZATION: Occurs in more than 30% of individuals who are stung; disappears 2 to 3 years after a sting in 40% of cases (Golden et al, 1989).
e) PREVALENCE: Based on several studies, the incidence of systemic allergic reactions after Hymenoptera stings in the general population ranged from 0.15% to 3.3%; 26.5% had IgE antibodies to Hymenoptera venom. It appears that the majority of individuals who have venom IgE antibodies have never experienced an allergic reaction (Charpin et al, 1992; Golden et al, 1989).
f) RISK FACTORS
g) LATE-ONSET ALLERGIC REACTIONS: Effects may occur several hours to as long as 10 days after a sting and range from typical anaphylactic and serum sickness-like reactions, including local swelling, urticaria, throat edema, generalized rash, fever, lymphadenopathy, swelling, and arthralgia. These effects may be mediated by venom-specific IgG and venom-specific IgE (Lazoglu et al, 1995; Reisman, 1991; Reisman & Livingston, 1989).

1) Approximately 90% of individuals with histories of systemic or large local sting reactions will have a positive VST, manifested by a specific wheal and flare reaction to one or more venoms at a concentration of 1 microgram/milliliter or less.