- Patient has been stung on the side of his face by a bee
- The stinger is removed from the skin by tweezers; an ice-pack
is applied to the sting site
- The patient is given 50 mg oral diphenhydramine
- After 10 minutes, the swelling begins to subside
- The patient is escorted home and follows up with his primary
doctor the next day
Follow-up evaluation strategy
- The patient has moderate persistent hemifacial and periocular
swelling; because the edema around his eye obstructs his vision, he
is given a prescription for a 5-day course of prednisone 1
- He is referred to an allergist for evaluation and consideration
of venom immunotherapy
- He is referred to an ophthalmologist for evaluation given the
dramatic periocular involvement
- He is given a prescription for supplies for an emergency kit:
systemic antihistamines, systemic corticosteroids, and an
epinephrine auto-injection pen to carry with him at all times
The order hymenoptera includes bees, wasps, hornets, and ants.
Hymenoptera stings cause toxic and allergic reactions.
Toxic reactions, also termed local reactions, result from the
local tissue effects of venom containing histamine, hyaluronidase,
mellitin, or phospholipase. Toxic reactions are often mild and last
several hours. Localized pain, edema, fever, urticaria, serum
sickness, and arthralgias may ensue. They can be severe or even
fatal if a person is stung numerous times.
Allergic responses are Immunoglobulin E (IgE) dependent and
present in previously sensitized individuals as a local exaggerated
reaction or a generalized systemic (anaphylactic) reaction. Local
exaggerated reactions are characterized by erythema, swelling, and
itching which extend beyond the site of the sting. Anaphylaxis is
characterized by rapidly developing symptoms which may compromise
circulatory and respiratory symptoms. Anaphylaxis is a medical
emergency requiring prompt diagnosis and immediate emergent
management. Risk factors for anaphylaxis include a history of
repeated stings and may be an occupational hazard for those
frequently exposed to these insects; other associated risk factors
include male gender, older age, elevated serum tryptase level,
cutaneous or systemic mastocytosis, and medications such as
angiotensin-converting enzyme inhibitors. Vespid (wasp) stings are
more commonly associated with anaphylactic reactions.
Hymenoptera members have distinct stinging patterns. Most nest
in the ground or in walls and sting only if provoked, with the
exception of African bees. Honeybees typically leave a barbed
ovipositor (stinger) in the skin, whereas bumble bees, wasps, and
hornets can withdraw their stinger. Ant stings are painful and
usually multiple; fire ant stings are notably painful. Tender
urticarial lesions may result along with the development of a
pruritic sterile pustule.
Any hymenoptera sting may cause eosinophilic cellulitis (Wells'
syndrome) with flame figures seen on histopathology. Dramatic
reactions, including anaphylaxis, may be a presenting manifestation
of mastocytosis and is not likely mediated by IgE.
Rueff F, et al. Management of occupational hymenoptera allergy.
Curr Opin Allergy Clin Immunol 2011;11(2):69-74.
Rueff F, et al. Stinging hymenoptera and mastocytosis. Curr Opin
Allerg Clin Immunol 2009;9:338-42.