Identification
The Hymenoptera order of insects includes Apidae (bees), Vespidae (wasps, yellow jackets, hornets), and Formicidae (fire ants). All 3 of these families of insects inject venom into their prey or as a defense mechanism via ovipositors in their abdomen. Vespids are the most aggressive and are found in each of the United States.1 They have membranous wings, broad antennae, and a nonbarbed stinger (Figure 1).2 The nonbarbed stinger of Vespidae differentiates them from Apidae and allows these insects to sting their prey multiple times. Vespids can build nests in the ground (yellow jackets), trees (hornets), or areas of cover such as window shutters (mud wasps). Because only the queens survive winter, larger populations do not develop until late summer when the most stings take place. Stings most often take place near the nest of the vespid or while the victim is eating outdoors.3
Figure 1. Vespids. A, The anatomy of a hornet. B, A brilliant image of a yellow jacket. C, A detailed image of a wasp.
Envenomation
When vespids sting their prey they inject venom via their ovipositors.1 The venom is composed of a mixture of low-molecular-weight proteins, kinins, proteolytic enzymes, lipids, carbohydrates, and high-molecular-weight proteins that act as allergens.1,4,5 The proteolytic enzymes degrade the surrounding tissue, basophils become activated, and histamine is released secondary to mast cell degranulation, which results in vasodilation and an inflammatory response characterized by edema, erythema, warmth, and pain.1 The pain of the sting is immediate and can be intense; almost all victims are acutely aware of the discomforting sensation.4
Management of Reactions
Three types of reactions can be seen after a vespid sting: uncomplicated local reactions, large local reactions, and systemic reactions (SRs). The most common reaction is the self-limiting uncomplicated local reaction that includes a focal area of warmth, edema, erythema, induration, and tenderness.1 Treatment of this kind of reaction is supportive, with ice, nonsteroidal anti-inflammatory drugs, and H1 and H2 blockers being commonly used methods. Large local reactions (Figure 2) are similar to uncomplicated local reactions but are greater than 10 cm in diameter and last longer. The same symptomatic treatment may be used along with possible short (3–5 days) oral glucocorticoid (40–60 mg prednisone) or potent topical steroid administration if symptoms persist. Systemic reactions involve IgE-mediated generalized urticaria, angioedema, face swelling, stridor, bronchospasm, nausea, vomiting, flushing, and respiratory distress.1 Emergency management includes maintenance of airway, breathing, and circulation. Epinephrine injection commonly is employed and should be given via intramuscular injection into the anterolateral thigh; a dose of 0.3 to 0.5 mg can be repeatedly injected every 5 to 15 minutes, as needed.1
Figure 2. A large local reaction after a wasp sting.
If an individual has an SR, it is recommended to go to an emergency department after stabilization for monitoring. Referral to an allergist for desensitization is appropriate. A radioallergosorbent test to measure allergen-specific IgE can be helpful to confirm an allergy.4 This test also should be done weeks after the incident because during the first few days IgE may be too low to measure. Once the allergy is confirmed, the desensitization with venom immunotherapy (VIT) can begin. Venom immunotherapy is effective and reduces a patient’s risk for recurrent SRs to less than 5% to 20%.6 A 2015 study recommended longer duration of VIT therapy due to risk for repeat SRs after discontinuing therapy. This study concluded that VIT is to be administered for 5 years, unless the patient is at high risk for SRs after VIT therapy—risk factors include older age, cardiopulmonary disease, SR during VIT treatment, mast cell disorders, and elevated serum tryptase—in which case VIT may have to be continued indefinitely. It is recommended that all patients with history of SR carry an epinephrine autoinjector in case of emergency.6
Epidemiologic data show a prevalence of 0.3% to 7.5% for self-reported SRs due to stings, with lower prevalence in children (0.15%–0.3%).4,7 An additional study looking at data from an allergy practice determined 24% of all cases of anaphylaxis were due to insect stings.5
Conclusion
Although many vespid stings can be managed symptomatically, it is imperative for patients and providers to be aware of the possible severe reactions that can take place. It is essential for providers to be aware of how to care for and treat large local reactions and SRs, as symptom recognition and timely treatment can improve patient safety and result in better outcomes.