What is the appropriate management for a patient with no known history of allergies who has been stung by a bee and is at risk of an allergic reaction due to bee sting venom?

Management of Bee Sting in Patient with No Known Allergy History

For a patient with no known allergies who has been stung by a bee, provide immediate symptomatic care with cold compresses and oral antihistamines, monitor closely for 30-60 minutes for any signs of systemic reaction, and educate about warning signs that would require immediate epinephrine administration. 1, 2

Immediate Assessment and Monitoring

Watch for systemic allergic reaction symptoms during the first 10-60 minutes post-sting, as anaphylaxis typically develops within this timeframe. 2, 3 Key warning signs include:

• Urticaria or hives beyond the sting site
• Angioedema (swelling of face, lips, tongue, or throat)
• Respiratory symptoms (wheezing, shortness of breath, throat tightness)
• Cardiovascular symptoms (hypotension, tachycardia, dizziness, syncope)
• Gastrointestinal symptoms (nausea, vomiting, abdominal cramping)
• Neurological symptoms (confusion, loss of consciousness) 1, 4

If any systemic symptoms develop, administer epinephrine immediately 0.3-0.5 mg intramuscularly in the anterolateral thigh, as delayed epinephrine use is associated with fatal outcomes. 5, 2, 4 Antihistamines and corticosteroids are NOT substitutes for epinephrine in anaphylaxis. 5, 6

Local Reaction Management

For uncomplicated local reactions (the most likely scenario in a patient with no known allergies):

• Apply cold compresses to reduce local pain and swelling 1, 2
• Prescribe oral antihistamines (such as cetirizine) to reduce itching, pain, and inflammation 1, 2
• Provide oral analgesics for pain management 1, 6
• Elevate the affected limb if swelling is significant 1
• Remove the stinger promptly if still present (bees leave barbed stingers that continue to inject venom) 3

Large Local Reactions

If the patient develops extensive swelling extending beyond the sting site (typically peaking at 24-48 hours and lasting 5-10 days):

• Continue cold compresses and oral antihistamines 2, 6
• Consider a short course of oral corticosteroids for severe cases with extensive swelling, though definitive controlled trial evidence is lacking 1, 6
• Do NOT prescribe antibiotics unless there are clear signs of secondary bacterial infection (progressive redness, increasing pain, purulent discharge, fever, warmth and tenderness) 1, 6

Critical pitfall: Large local reactions are IgE-mediated allergic inflammation, NOT infection—antibiotics are inappropriate for allergic swelling. 1, 6

Risk Stratification and Follow-Up

Even without prior allergy history, approximately 3-8.9% of the general population can develop systemic allergic reactions to insect stings. 7, 8 The risk of future systemic reactions varies:

• Patients with only local reactions: Very low risk (<5%) of future systemic reactions; epinephrine prescription generally not necessary 5
• Patients who develop large local reactions: 5-10% risk of future systemic reactions; consider allergist referral if reactions involve vascular compromise or frequent unavoidable exposure 5, 1
• Patients who develop ANY systemic symptoms: Require immediate epinephrine, emergency department transport, allergist referral, and consideration for venom immunotherapy 1, 2

Post-Sting Instructions for Patients

Educate the patient to seek immediate emergency care if they develop:

• Hives or swelling away from the sting site
• Difficulty breathing or swallowing
• Dizziness, rapid pulse, or drop in blood pressure
• Nausea, vomiting, or diarrhea 4

For patients who develop systemic reactions: They should receive a prescription for an epinephrine autoinjector to carry at all times and be referred to an allergist-immunologist for venom-specific IgE testing. 1, 2 Venom immunotherapy (VIT) reduces the risk of subsequent systemic reactions to less than 5% and is highly effective. 5, 2

Special Considerations

Testing timing: If systemic reaction occurs and allergy testing is planned, skin tests and serum IgE measurements may be temporarily non-reactive within the first few weeks after a reaction and may require retesting at 6 weeks. 5, 1

Multiple stings: While most bee stings are not life-threatening, massive envenomations (>30 stings in children, estimated lethal dose ~20 stings/kg) can cause death from direct venom toxicity even without anaphylaxis. 9, 3 These patients require immediate emergency department evaluation.