Arthropod AllergyNathan Hare MD, FAAAAIAllergy Partners of Lewisburg10/29/14

http://goo.gl/Sq5WiU

Disclosures

• None

DisclaimerThis presentation is designed to present an

overview of this topic. This presentation is for informational and educational purposes only.

Those involved in the creation of this presentation, including Nathan Hare, M.D. and Allergy Partners, PA, will not be held responsible for any treatment taken by viewers as a result of their interpretations of the information provided.

Outline• Arthropods: Insects vs. arachnids• What is an allergy?• What is anaphylaxis?• What symptoms are consistent with

an allergic reaction?• Management of anaphylaxis• Routes of exposure for an allergic

reaction• Review of arthropod reactions• Route of exposure• Types of reactions• Management

What is an insect?• “an organism with … three body regions– head,

thorax, and abdomen.”

• It has 6 legs

• It has “a pair of antennae and external mouthparts.”

http://insects.about.com/od/insects101/p/whatisaninsect.htm

Identifying Insects

http://insects.about.com/od/insects101/ss/howtoidaninsect.htm

Insects

http://goo.gl/vTpeQQ

What is an Arachnid?• They have “two distinct regions, the

cephalothorax and the abdomen.”

• They have 8 legs.

• They “lack wings and antennae.”

http://insects.about.com/od/noninsectarthropods/p/arachnida.htm

Arachnids

http://goo.gl/vTpeQQhttp://goo.gl/7m3UFh

http://goo.gl/7MITvkhttp://goo.gl/MhEGXqhttp://goo.gl/kMl3Yg

What is an Allergy?• The immune system reacts to something

harmless (allergen)

• It thinks that the allergen is dangerous

• Symptoms are caused by the immune system trying to defend the body

• “Hypersensitivity”

Other reactions to arthropods• Irritation• Tarantula hairs

• Envenomation (poison)•Caterpillars with poisonous spines• Saddleback caterpillar• Puss Caterpillar

• Spider bitesBlack widowBrown recluse

http://goo.gl/XzLTw4Puss Caterpillar

• A rapid, sudden onset, life-threatening, allergic reaction.

What is Anaphylaxis?

Allergy /Anaphylaxis symptoms

• Mouth: Itchy, swelling of tongue and/or lips• Throat: Itchy, tightness/closure, hoarseness, trouble

breathing/swallowing • Skin: Itchy, hives, redness, swelling, red watery eyes • Gut: Nausea, vomiting, cramps, diarrhea• Lung: Short of breath, wheeze, repetitive cough • Heart: Pale or blue skin color, dizzy/faint, weak pulse • Neurological: Sense of “impending doom,”

irritability, change in alertness, mood change, confusion

http://goo.gl/Fp12Sp

Management of Anaphylaxis• Epinephrine• Epinephrine• Epinephrine

• Antihistamines• Oxygen• Airway support

• Epinephrine (repeat in 5 minutes if no improvement)•~25% of the time a second dose is needed• “If there is any doubt, it is generally better to administer epinephrine.”

• Benadryl• “H1 antihistamines are considered second line to epinephrine and should not be administered in lieu of epinephrine in the treatment of anaphylaxis.”

Management of Anaphylaxis

http://goo.gl/oDh4CD

Types of Allergic Reactions

• Immediate

• Delayed

Routes of Exposure• Bites

• Contact / Touch

• Inhalation / Breathing

• Injection / Sting

• Ingestion / Eating

Contact AllergensImmediate Delayed

http://goo.gl/v0lnnm

Latex Poison Ivy

Inhaled Allergens• Immediate

www.doctorfungus.org

http://goo.gl/2ZKoUx

Injected Allergens• Immediate

http://goo.gl/DVvcSJ

Ingested Allergens• Immediate • Delayed

http://goo.gl/mNRDPv

Public Domain: Mosquito, James Gathany, 2005 (CDC)http://goo.gl/tXXSiO

Mosquitoes (Insect)

• Exposure: Bites

• Type of Reaction: Allergic (delayed or immediate)

• Symptoms: • Local allergic reaction• Large local reaction (Skeeter Sydrome)• Rarely, hives, anaphylaxis, or other immune reaction

• Treatment: Symptomatichttp://goo.gl/SanNFhUpToDate: Author F Estelle R Simons, MD, FRCPC Large local reactions to mosquito bites (Skeeter syndrome)

Flies (Insect)• Black Flies, Horse Flies

• Exposure: Bites

• Type of Reaction• Allergic (delayed or immediate)

• Symptoms: • Local allergic reaction• Anaphylaxis• Black Flies: Late systemic syndrome characterized by fever,

leukocytosis, lymphadenitis, and papular lesions.

• Treatment: Symptomatichttp://goo.gl/wWieEi

UpToDate: Insect bites Author Mariana C Castells, MD, PhDhttp://goo.gl/QE3GDW

Chiggers (Arachnid)• larvae of the Trombiculidae family, a type of mite

• Exposure: Bites

• Type of Reaction: Allergic (delayed, possibly immediate)

• Symptoms: • Local allergic reaction• Rarely, hives, blistering or other rash

• Treatment: SymptomaticBy: CDC/ Dr. Cornelius B. Philip, Nat. Inst. of Allergy and Infectious Diseases (NIAID), Rocky Mountain Laboratories (RML), Courtesy: Public Health Image Libraryhttp://goo.gl/m0cEjp

http://goo.gl/fBWgp8

UpToDate: Chigger bitesAuthors:Helge Riemann, MDWhitney A High, MD http://goo.gl/vBTHsr

Scabies Mites (Arachnid)• Exposure: Bites and Burrows

• Type of Reaction: Allergic (delayed-type)

• Symptoms: • Local allergic reaction• Diffuse itching, worse at night

• Treatment: • Symptomatic• Eradication with medication (oral ivermectin, topical

permethrin)http://goo.gl/BlCJ23

UpToDate: Scabies Authors: Beth G Goldstein, MD, Adam O Goldstein, MD, MPHhttp://goo.gl/s2daHI

Bedbugs (Insect)• Exposure: Bites

• Type of Reaction: Allergic (delayed)

• Symptoms: • Local allergic reaction

• Treatment: • Symptomatic• Eradication

By: CDC/ Harvard University, Dr. Gary Alpert; Dr. Harold Harlan; Richard Pollack, Courtesy: Public Health Image Library http://goo.gl/z0XZps

Biting Midges (No-see-ums): Insect• Exposure: Bites

• Type of Reaction: Allergic (delayed)

• Symptoms: • Local Allergic Reaction

• Treatment: Symptomatic

UpToDate: Insect bites Author Mariana C Castells, MD, PhDhttp://goo.gl/QE3GDW

http://goo.gl/IwwKUZ

Ticks (Arachnid)• Exposure: Bites

• Type of Reaction: Irritation, Allergic (delayed or immediate)

• Symptoms: • Rarely, anaphylaxis• Development of a meat allergy related to sensitization to

a carbohydrate in the tick’s saliva

• Treatment: Symptomatichttp://goo.gl/7MITvkUpToDate: Insect bites Author Mariana C Castells, MD, PhD

http://goo.gl/QE3GDW

Fleas (Insect)• Exposure: Bites

• Type of Reaction: Allergic (delayed or immediate)

• Symptoms: • Local allergic reaction• Rarely, respiratory symptoms, especially if cat allergic

• Treatment: • Symptomatic• Eradication

By: CDC/ Janice Haney Carr, Courtesy: Public Health Image Libraryhttp://goo.gl/N7xiLC

UpToDate: Insect bites Author Mariana C Castells, MD, PhDhttp://goo.gl/QE3GDW

Multicolored Asian Ladybeetle (Insect)• Exposure: Contact, Bites, Inhalation

• Type of Reaction: Allergic (immediate)

• Symptoms: • Eye and Nose Symptoms• Chronic cough• Asthma• Hives / Swelling

• Treatment: • Symptomatic• Eradication

http://goo.gl/EfR91b

Nakazawa T1, Satinover SM, Naccara L, Goddard L, Dragulev BP, Peters E, Platts-Mills TA.Asian ladybugs (Harmonia axyridis): a new seasonal indoor allergen.J Allergy Clin Immunol. 2007 Feb;119(2):421-7.

Cochineals (Insect)• A scale insect that lives on cacti in Central and South America• Used to make Red Dye for food coloring, cosmetics

• Cochineal, or Carmine

• Exposure: Contact, Inhalation, Ingestion

• Type of Reaction: Allergic (delayed or immediate)

• Symptoms: • Asthma• Hives• Anaphylaxis• Contact Dermatitis

• Treatment: • Symptomatic• Avoidance http://goo.gl/oI6SF9

http://goo.gl/Guwo7j

Cockroaches:Insect• Exposure: Inhalation, Contact, Ingestion (chocolate, peanut

butter, macaroni, fruit, cheese, popcorn and wheat)

• Type of Reaction: Allergic (immediate)

• Symptoms: • Eye and Nose Symptoms• Asthma

• Treatment: • Symptomatic• Eradication• Allergy Immunotherapy

http://goo.gl/RNBRb3By: CDC, Courtesy: Public Health Image Library

Per ABC news: Average chocolate barhas 8 insect parts http://goo.gl/q8B1W

Dust Mites (Arachnid)• 0.3 mm long• 8 legs• Sightless• Live on skin scales• Entirely dependent on

ambient humidity for their moisture

• Optimum growth at 65-80oF

• Mite fecal pellet• Source of allergens• 10-35 μm

• Dermatophygoides farinae

• D. pteronyssinus• D. microceras• Blomia tropicalis• Florida in the US

Dust Mites (Arachnid)• Exposure: Inhalation, Contact

• Type of Reaction: Allergic (immediate)

• Symptoms: • Eye and Nose Symptoms• Asthma

• Treatment: • Symptomatic• Avoidance – Environmental Modifications• Allergy Immunotherapy

http://goo.gl/kMl3Yg

House dust mite avoidance measures for perennial Allergic Rhinitis

• 2010 Cochrane Review, assessed as up to date end of 2009.1

• 9 trials (501 participants satisfied criteria)

•Mite-impermeable bedding covers (2 studies were good quality)• Acaricides (2 studies)• HEPA filters (2 studies)• Acaricides +/- covers (1 study)

1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group: House dust mite avoidance measures for perennial allergic rhinitis Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009

House dust mite avoidance measures for perennial Allergic Rhinitis• Conclusions:• Trials to date … small and of poor methodological

quality…difficult to offer any definitive recommendations on the role … of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis.

• Use of acaricides and extensive bedroom-based environmental control programmes may be of some benefit in reducing rhinitis symptoms and, if considered appropriate, these should be the interventions of choice.

• Isolated use of house dust mite impermeable bedding is unlikely to prove effective.1. Aziz Sheikh1,*, Brian Hurwitz2, Ulugbek Nurmatov3, Constant Paul van Schayck4 Editorial Group:

House dust mite avoidance measures for perennial allergic rhinitis Cochrane Ear, Nose and Throat Disorders Group Published Online: 7 JUL 2010 Assessed as up-to-date: 30 DEC 2009

Stinging Insects• Honeybees• Wasps• Yellow jackets / hornets• Fire ants

Honey Bee (Insect)

http://goo.gl/vTpeQQ

Paper Wasps (Insect)

http://goo.gl/npB2bE

Yellow Jackets & Hornets (Insect)

http://goo.gl/BaVTND

By: CDC/ Harvard University, Dr. Gary Alpert, Courtesy: Public Health Image Libraryhttp://goo.gl/g4HSm3

Fire Ants (Insect)

http://goo.gl/ItNZxe

• An estimated 0.4-0.8% of children, and 3% of adults, have potentially life-threatening reactions to stings.

• Honey Bee• Yellow Jacket• Yellow-Faced Hornet• White-Faced Hornet• Paper Wasp

• Fire Ant

Stinging Insect Allergy

http://goo.gl/wi7PFc

• Stinging insects such as bees, wasps, hornets and yellow jackets, are most active during late-summer and early-autumn

• Fire ants are prevalent year round in the South

Stinging Insect Allergy

http://goo.gl/povKLPhttp://goo.gl/YXhxoP

Fatal Anaphylaxis in the U.S.:1999-2010• Analysis of the National Mortality Database

• 2458 fatal anaphylaxis cases in the U.S. of all causes

• 0.69 persons per million

Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]

Fatal Anaphylaxis: Venom• Rate• Differed by race• 0.14 per million in white subjects • 0.05 per million in African American subjects• 0.03 per million in Hispanic subjects

• Increased with age• 0.01 per million if ≤ 19 years• 0.20 per million if age 60 to 79 years

Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]

Fatal Anaphylaxis: Venom• Rate• Differed by gender• 0.18 per million for male subjects• 0.04 per million for female subjects

• no significant increase over time

Jerschow E1, Lin RY2, Scaperotti MM3, McGinn AP4. Fatal anaphylaxis in the United States, 1999-2010: Temporal patterns and demographic associations.J Allergy Clin Immunol. 2014 Sep 26. pii: S0091-6749(14)01190-7. doi: 10.1016/j.jaci.2014.08.018. [Epub ahead of print]

• Children <16 years of age

• Family History: No evaluation needed• Never had a reaction: No evaluation needed• Local reaction only: No evaluation needed• Skin reaction only: No evaluation needed

Epinephrine auto-injector not needed

• Anaphylaxis: Evaluation neededEpinephrine auto-injector

needed

Stinging Insect Allergy: Who is at risk of Anaphylaxis if stung again?

Golden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol. Stinging insect hypersensitivity: a practice parameter update 2011.2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.

• Adults and Children ≥16 years of age

• Local reaction only: No evaluation needed

• Skin reaction (hives and swelling): Increased risk of anaphylaxis

Evaluation neededEpinephrine auto-injector needed

• Anaphylaxis: Evaluation neededEpinephrine auto-injector needed

Stinging Insect Allergy: Who is at risk of Anaphylaxis if stung again?

Golden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol. Stinging insect hypersensitivity: a practice parameter update 2011.2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.

• Venom allergy immunotherapy•Decreases risk of anaphylaxis from 30-60% to <5%

• Venom Allergy Anaphylaxis Action Plan• Have injectible epinephrine on hand (2 doses)• Medical Alert Bracelet• Behavior modifications to reduce risk of

exposure

Stinging Insect Allergy: Management

Golden DB1, Moffitt J, Nicklas RA, Freeman T, Graft DF, Reisman RE, Tracy JM, Bernstein D, Blessing-Moore J, Cox L, Khan DA, Lang DM, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles SA, Wallace D; Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology. J Allergy Clin Immunol. Stinging insect hypersensitivity: a practice parameter update 2011.2011 Apr;127(4):852-4.e1-23. doi: 10.1016/j.jaci.2011.01.025.

Summary: Part 1• Insects have 3 body segments, 6 legs and 2

antennae

• Arachnids have 2 body segments, 8 legs, and no antennae

• An Allergic reaction is an immune reaction to a trigger

• Allergic reactions to arachnids can occur through contact, bites, inhalation, ingestion, and injection.

Summary: Part 2• Allergic reactions to arachnids can range

from mild and local, to severe, life-threatening and systemic

• Venom allergy immunotherapy can greatly reduce the future risk of anaphylaxis

• Epinephrine is the treatment of choice for anaphylaxis

Questions? Comments?

Nathan Hare MD, FAAAAI

570-522-8111 (office)ndhare@allergypartners.com@AllergyTalk, @ AP_Lewisburghttps://www.facebook.com/APLewisburg

Thank you!