- Author: Hemant H Vankawala, MD; Chief Editor: Scott H Plantz, MD, FAAEM more...
Hymenoptera stings account for more deaths in the United States than any other envenomation. The order Hymenoptera includes Apis species, ie, bees (European, African), vespids (wasps, yellow jackets, hornets), and ants. Although most deaths result from immunologic mechanisms, some are from direct toxicity. Severe anaphylactoid reactions occur occasionally when toxins directly stimulate mast cells. While the vast majority of stings cause only minor problems, stings cause a significant number of deaths.
See Arthropod Envenomation: From Benign Bites to Serious Stings, a Critical Images slideshow, for help identifying and treating various envenomations. See also All About Allergies: Be Ready for Spring, to help identify a variety of allergens and symptoms.
Target organs are the skin, vascular system, and respiratory system. Pathology is similar to other immunoglobulin E (IgE)–mediated allergic reactions. Anaphylaxis may occur and is typically a result of sudden systemic release of mast cells and basophil mediators. Urticaria, vasodilation, bronchospasm, laryngospasm, and angioedema are prominent symptoms of the reaction. Respiratory arrest may result in refractory cases.
Ants sting 9.3 million people each year. Other Hymenoptera species account for more than 1 million stings annually. Anaphylaxis secondary to Hymenoptera envenomation affects roughly 3% of the general population. Systemic reactions leading to life-threatening manifestations occurs in approximately 0.4-0.8% of children and 3% of adult patients.
According the US Bureau of Labor Statistics, from 2003 to 2010, bees accounted for 52 fatal occupational injuries, wasps/yellow jackets 14, and ants 4 . Additionally, fatal occupational injuries involving insects, by year, are as follows :
2003: 6 deaths
2004: 10 deaths
2005: 15 deaths
2006: 10 deaths
2007: 11 deaths
2008: 10 deaths
2009: 9 deaths
2010: 12 deaths
A 2009 study from Costa Rica reported on Hymenoptera sting fatalities over a 22-year period (1985-2006). The annual number of deaths varied from 0-6 (2.4 deaths/year average), with a total of 52 deaths over the study period. Most deaths were in older (>50 years) and younger (< 10 years) males.
From 1979 through 1978, 7 fatalities from wasp stings were reported in Australia, all from rural areas; 5 of the 7 had a history of wasp or bee venom allergy.
No race predilection exists.
Hymenoptera stings of all types are more common in males than in females, probably because of more frequent exposure.
Although most deaths from toxic reactions occur at extremes of age, frequency of bites is not age dependent. Peak incidence of death from anaphylaxis is in people aged 35-45 years.
[Guideline] The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. 2005 Mar. 115(3 Suppl 2):S483-523. [Medline].
Galera C, Soohun N, Zankar N, Caimmi S, Gallen C, Demoly P. Severe anaphylaxis to bee venom immunotherapy: efficacy of pretreatment and concurrent treatment with omalizumab. J Investig Allergol Clin Immunol. 2009. 19(3):225-9. [Medline].
Hernandez M, Gonzalez S, Galindo G, Iaz A, Rodriguez P. University Hospital, et al. Reactions to hymenoptera sting in adult patients: experience in a clinical allergy/immunology service in Monterrey Mexico. World Allergy Organization Journal. 2007/11. S216-S217.
Pegula S, Kato A. Fatal injuries and nonfatal occupational injuries and illnesses involving insects, arachnids, and mites. Workplace Injuries. Aug 2014. 3(17):[Full Text].
Prado M, Quirós D, Lomonte B. Mortality due to Hymenoptera stings in Costa Rica, 1985-2006. Rev Panam Salud Publica. 2009 May. 25(5):389-93. [Medline].
McGain F, Harrison J, Winkel KD. Wasp sting mortality in Australia. Med J Aust. 2000 Aug 21. 173(4):198-200. [Medline].
Tarpy D. Africanized Honey Bees: Where Are They Now, and When Will They Arrive in North Carolina. NC State Cooperative Extension. Available at http://content.ces.ncsu.edu/africanized-honey-bees-where-are-they-now-and-when-will-they-arrive-in-north-carolina/. February 5, 2015; Accessed: September 23, 2015.
Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet. 1996 Aug 3. 348(9023):301-2. [Medline].
De Soto H, Turk P. Cimetidine in anaphylactic shock refractory to standard therapy. Anesth Analg. 1989 Aug. 69(2):264-5. [Medline].
Sokol KC, Ghazi A, Kelly BC, Grant JA. Omalizumab as a desensitizing agent and treatment in mastocytosis: a review of the literature and case report. J Allergy Clin Immunol Pract. 2014 May-Jun. 2(3):266-70. [Medline].
Valkanas MA, Bowman S, Dailey MW. Electrocardiographic myocardial infarction without structural lesion in the setting of acute hymenoptera envenomation. Am J Emerg Med. 2007 Nov. 25(9):1082.e5-8. [Medline].
Betten DP, Richardson WH, Tong TC. Massive honey bee envenomation-induced rhabdomyolysis in an adolescent. Pediatrics. 2006 Jan. 117(1):231-5. [Medline].
Reisman RE. Unusual reactions to insect stings. Curr Opin Allergy Clin Immunol. 2005 Aug. 5 (4):355-8. [Medline].
Rekik S, Andrieu S, Aboukhoudir F, Barnay P, Quaino G, Pansieri M, et al. ST Elevation Myocardial Infarction with No Structural Lesions after a Wasp Sting. J Emerg Med. 2009 Mar 26. [Medline].
Vachvanichsanong P, Dissaneewate P. Acute renal failure following wasp sting in children. Eur J Pediatr. 2009 Jan 16. [Medline].
Langley RL. Animal-related fatalities in the United States-an update. Wilderness Environ Med. 2005. 16(2):67-74. [Medline].
Rhoades RB, Stafford CT, James FK Jr. Survey of fatal anaphylactic reactions to imported fire ant stings. Report of the Fire Ant Subcommittee of the American Academy of Allergy and Immunology. J Allergy Clin Immunol. 1989 Aug. 84(2):159-62. [Medline].