What is the management for a patient with a history of allergic reactions and without, after being stung by a bee?

Bee Sting Management

Immediate Management Based on Reaction Type

For patients presenting with anaphylaxis (systemic reaction beyond the sting site), immediately administer intramuscular epinephrine 0.3-0.5 mg into the anterolateral thigh and activate emergency medical services—this single intervention is the most critical life-saving action. 1

Step 1: Remove the Stinger Immediately

• Scrape or flick the stinger away with a fingernail or tweezers as soon as possible, as venom delivery continues for up to 60 seconds 2, 3
• The method of removal (scraping vs. pinching) does not matter—speed is what counts, with removal within 2 seconds showing no difference in envenomization regardless of technique 3
• This takes priority over any medication administration for local reactions 2

Step 2: Identify the Type of Reaction

Local Reactions (confined to sting site): 4

• Redness, swelling, itching, and pain at the sting site
• No treatment usually required for mild cases

Large Local Reactions (extending beyond sting site): 4

• Swelling increases for 24-48 hours
• Extends more than 10 cm in diameter contiguous to the sting site
• Takes 5-10 days to resolve
• IgE-mediated but almost always self-limited

Systemic Reactions (NOT contiguous with sting site): 4

• Cutaneous: Urticaria, angioedema, flushing
• Respiratory: Hoarseness, throat tightness, stridor, bronchospasm, wheezing, difficulty breathing
• Cardiovascular: Hypotension, shock, arrhythmias
• Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain
• Neurological: Seizures

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Treatment Protocols

For Local Reactions (No History of Allergy)

• Apply cold compresses to reduce pain and swelling 4
• Administer oral antihistamines (e.g., diphenhydramine) for itching 4
• Provide oral analgesics (acetaminophen or NSAIDs) for pain 2
• Do NOT prescribe antibiotics—the swelling is allergic inflammation, not infection, and antibiotics are a common error unless there is clear evidence of secondary infection (purulent drainage, fever, progressive worsening beyond 48-72 hours) 4, 5

For Large Local Reactions (No History of Allergy)

• Apply topical corticosteroids directly to the sting site for local itching and inflammation 2
• Combine with cold compresses and oral antihistamines 2
• For severe large local reactions with extensive swelling, initiate a short course of oral corticosteroids promptly within the first 24-48 hours to limit progression 4, 2
• The American Academy of Allergy, Asthma, and Immunology supports oral corticosteroids for severe cases, though controlled trial data is limited 4, 2
• Critical pitfall: Do not mistake allergic swelling and lymphangitis for bacterial cellulitis, which leads to inappropriate antibiotic prescribing 5
• Injectable epinephrine prescription is optional for these patients but may be considered for reassurance 4

For Systemic Reactions (Anaphylaxis)

Immediate Actions:

1. Administer intramuscular epinephrine immediately 1, 6

   • Adult dose: 0.3-0.5 mg (depending on severity)
   • Pediatric dose: 0.01 mg/kg (maximum 0.3 mg in prepubertal children, up to 0.5 mg in teenagers)
   • Inject into the mid-outer thigh (vastus lateralis muscle)
   • IM injection in the anterolateral thigh achieves faster and higher plasma concentrations than subcutaneous or arm injections 1

2. Call emergency services immediately after administering epinephrine 1

3. Position patient supine with legs elevated if hypotension develops, to prevent sudden death from "empty-ventricle syndrome" 1

4. Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist or worsen 1

   • Delayed or inadequate epinephrine use is associated with fatal outcomes 4, 1

Adjunctive Therapies (after epinephrine):

• Administer 1-2 liters of IV normal saline bolus for persistent hypotension, as massive fluid shifts occur during anaphylaxis 1
• Provide supplemental oxygen to all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses 1
• Give inhaled albuterol (2.5 mg nebulized) for bronchospasm persisting despite epinephrine 1
• Administer H1 antihistamines (diphenhydramine 25-50 mg IV/IM in adults) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts, but these do NOT treat life-threatening symptoms 1
• Give corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect 1
• Corticosteroids play NO role in acute anaphylaxis management—epinephrine is the primary treatment 2

Special Considerations:

• Patients with coexisting conditions (hypertension, cardiac arrhythmias) or taking β-adrenergic blocking agents require special attention, but there is NO contraindication to epinephrine in life-threatening anaphylaxis 4
• Coexisting asthma (especially if severe or poorly controlled) significantly increases the risk of severe or fatal reactions 1
• Laryngeal edema is the most common cause of death from Hymenoptera-induced anaphylaxis 1

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Management for Patients WITH History of Allergic Reactions

Risk Stratification

Low-Risk Patients (may not require epinephrine autoinjector): 4

• History of only large local reactions
• History of strictly cutaneous systemic reactions (isolated skin manifestations)
• Patients receiving maintenance venom immunotherapy (VIT)
• Patients who discontinued VIT after more than 5 years of treatment

High-Risk Patients (require epinephrine autoinjector and VIT consideration): 4

• History of extreme or near-fatal reactions
• Systemic reactions during VIT (to injection or sting)
• Severe honeybee allergy
• Underlying medical conditions (cardiovascular disease, mastocytosis)
• Frequent unavoidable exposure
• Elevated baseline serum tryptase or mastocytosis (found in 3-5% of patients with sting anaphylaxis) 7

Diagnostic Workup

All patients with systemic reactions should be referred to an allergist-immunologist for: 4, 1

• Skin testing or in vitro testing for specific IgE antibodies to insect venoms 4
• Testing should include honeybee, yellow jacket, white-faced hornet, yellow hornet, and wasp venom extracts 4
• A positive intradermal skin test at concentration ≤1.0 mg/mL demonstrates specific IgE antibodies 4
• If testing is negative within the first few weeks after a systemic reaction, repeat testing in 6 weeks, as tests may be temporarily non-reactive 4
• Measure baseline serum tryptase if systemic reaction extends beyond the skin (Ring and Messmer grade >I) to screen for mastocytosis 8

Venom Immunotherapy (VIT) Indications

VIT is indicated for: 4

• Patients with history of systemic reactions (beyond isolated cutaneous manifestations) who have positive skin or in vitro tests for specific IgE antibodies
• VIT reduces the risk of subsequent systemic reactions from 25-70% to less than 5% 4, 1
• VIT is extremely effective and can reduce future anaphylaxis risk to nearly zero 1

VIT is generally NOT necessary for: 4

• Children ≤16 years with isolated cutaneous systemic reactions without other systemic manifestations
• Patients with only large local reactions (though may be considered with frequent unavoidable exposure) 4

VIT is controversial but usually recommended for: 4

• Adults with only cutaneous manifestations of systemic reactions

Epinephrine Autoinjector Prescription

Prescribe epinephrine autoinjector (EpiPen or equivalent) for: 4, 1

• All patients with history of systemic reactions beyond isolated cutaneous manifestations
• Patients with history of extreme or near-fatal reactions
• High-risk patients as defined above
• Demonstrate proper use before discharge 1

Epinephrine autoinjector is optional for: 4

• Patients with history of only large local reactions (if it provides reassurance)
• Patients with history of only cutaneous systemic reactions (decision made through patient-physician discussion)

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Prevention and Long-Term Management

Patient Education on Avoidance

• Avoid walking barefoot outdoors 1
• Wear protective clothing when outdoors 1
• Avoid bright colors and floral patterns 1
• Eliminate scented products (perfumes, lotions) 1
• Have nests professionally removed 1

Follow-Up Care

• Refer all patients with systemic reactions to an allergist-immunologist for comprehensive evaluation and VIT consideration 1
• VIT should be continued for 3-5 years in most patients, with longer or permanent therapy considered for high-risk patients (mastocytosis, history of cardiovascular/respiratory arrest, hereditary α-tryptasemia) 8
• Patients on VIT should carry emergency kits including epinephrine autoinjector during treatment and after termination if they had grade ≥III reactions 8