Difficult to diagnose cases of Hymenoptera venom allergy (HVA)

In HVA with potentially life-threatening systemic allergic reactions, correct identification of the culprit
insect venom is crucial for specific immunotherapy. In up to 50% of all cases, diagnosis with intradermal skin testing and determination of specific IgE (e.g. UniCAP, Phadia Uppsala, Sweden) is not straight forward, and thus, the results are either not corresponding or even contradictory. In a few patients with a compelling history of HVA, these tests are completely negative. In such cases the basophil activation test (BAT) can be helpful in identification of the culprit insect venom.

References:

  • Scherer K. et al. Cellular in vitro Assays in the Diagnosis of Hymenoptera Venom Allergy. Int Arch Allergy Immunol. 2008 Jan 18;146(2):122-132
  • Eberlein-König B et al. Use of CD63 expression as marker of in vitro basophil activation in identifying the culprit in insect venom allergy. J Investig Allergol Clin Immunol. 2004;14(1):10-6.
  • Jappe U. et al., In vitro hymenoptera venom allergy diagnosis: improved by screening for cross-reactive carbohydrate determinants and reciprocal inhibition. Allergy 2006 Oct; 61(10): 1220-9
  • Ebo DG et al., Hymenoptera venom allergy: taking the sting out of difficult cases. J Investig Allergol Clin Immunol. 2007;17(6):357-6

Follow-up of Immunotherapy in HVA

The 5-year long specific immunotherapy (VIT) for insect venom allergy is effective and safe. Unfortunately, 5-20% of treated patients are not fully protected and still react on sting challenge (SC) with the living insect (performed in specialized centres). Therefore the time consuming and potentially dangerous SC is still necessary to proove the success of VIT. Recently, the basophil activation test (BAT) has shown to be helpful in identifying the unprotected individuals and has therefore the potential to replace SC. Basophils of patients are stimulated with a broad concentration range of the respective insect venom and the basophil sensitivity is determined. The shift of basophil sensitivity during VIT seems to correlate with venom tolerance in vivo. It is therefore advantageous and important to measure the individual basophil sensitivity before immunotherapy to document the shift during VIT.

References:

  • Ebo DG et al. Basophil activation test by flow cytometry: Present and future applications in allergology. Cytometry B Clin Cytom. 2008 Apr 15 [Epub ahead of print]
  • Ebo DG et al. Flow-assisted quantification of in vitro activated basophils in the diagnosis of wasp venom allergy and follow-up of wasp venom immunotherapy. Cytometry B Clin Cytom. 2007 May;72(3):196-203
  • Erdmann SM et al. The basophil activation test in wasp venom allergy: sensitivity, specificity and monitoring specific immunotherapy. Allergy. 2004 Oct;59(10):1102-9

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