eMedicine Specialties > Emergency Medicine > Environmental

Hymenoptera Stings

Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center

Updated: Apr 9, 2009

Introduction

Background

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.

A paper wasp (Randy Park, MD)

Pathophysiology

Target organs are the skin, vascular system, and respiratory system. Pathology is similar to other immunoglobulin E (IgE)–mediated allergic reactions. Urticaria, vasodilation, bronchospasm, laryngospasm, and angioedema are prominent symptoms of the reaction. Respiratory arrest may result in refractory cases.

Frequency

United States

Ants sting 9.3 million people each year. Other Hymenoptera account for more than 1 million stings annually.

Mortality/Morbidity

• Large local reactions occur in 17-56% of those stung. In one study, 1-2% experienced a generalized reaction, and 5% sought medical care.
• In 1989, 32 deaths were reported from fire ant stings in Texas, Florida, Louisiana, and Georgia.¹
• Wasps and bees cause 30-120 deaths yearly in the United States.

Race

No race predilection exists.

Sex

Hymenoptera stings of all types are more common in males than in females, probably because of more frequent exposure.

Age

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.

Clinical

History

• A patient's reaction to a Hymenoptera sting determines the treatment required. Reactions may be graded as local, urticaria without systemic symptoms, and generalized. Emergency physicians should attempt to determine degree of reaction based on both patient history and a physical examination.
• Rapid onset of symptoms is the rule; 50% of deaths occur within 30 minutes of the sting, and 75% occur within 4 hours.
• Fatal allergic reactions can occur as the first generalized reaction. Far more common, however, is a fatal reaction following a previous, milder generalized reaction. The shorter the interval since the last sting, the more likely it is that a severe reaction will take place.
• Large local reactions do not predispose patients to generalized reactions. Local reactions may be life threatening if local swelling at the sting site compromises the airway. Local reactions to stings can cause peripheral nerve block.
• Local reactions may produce the following:
  • Pain occurs immediately after sting.
  • Edema is marked and may extend to 10 cm from site of envenomation.
  • The insect frequently is seen by patient and may be identified from the description.
  • Bleeding may occur at site of sting.
  • Pruritus is common.
  • Vasodilation may produce a sensation of warmth.
  • The stinging apparatus may have been seen in the wound and removed prior to presentation.
  • Nausea or vomiting may occur without generalization.
  • Visceral pain may occur with stings in the gastrointestinal (GI) tract after ingestion of the insect.
• Urticaria may occur with or without the symptoms noted in local reaction.
• Generalized reactions may produce the following symptoms:
  • Urticaria
  • Confluent red rash
  • Shortness of breath, wheezing
  • Edema in airway, tongue, or uvula
  • Weakness, syncope
  • Anxiety, confusion
  • Chest pain

Physical

• Local reactions may include the following:
  • Erythema, edema, warmth, tenderness
  • Drainage from site of sting
  • Compromised distal circulation as result of edema
  • Distal sensation loss from stings over peripheral nerve
  • Corneal ulceration from corneal stings
  • With bee stings, stinging apparatus visible at sting site
  • Ant stings: Vesicles from fire ants, classic arc of fire ant stings, and ant stings on mucous membranes or conjunctival surfaces cause dramatic swelling in patients who are sensitive.

Two fire ant stings that are 24 hours old (Randy Park, MD)

• Urticaria or generalized redness may develop without systemic symptoms.
• Generalized reactions may include the following symptoms:
  • Urticaria
  • Vomiting
  • Wheezing
  • Tachypnea
  • Hypotension
  • Laryngoedema, lingular edema, uvular edema
  • Delirium, shock
  • Respiratory arrest

Causes

• Hymenoptera are social creatures that typically sting to protect their colony, nest, or hive. Most stings are incited by proximity to the colony. Noisy or vigorous activity (eg, lawn mowers, weed eaters), bright or dark colors, and perfumes also may incite stings. In addition, these insects can release defense pheromones that attract other insects and induce them to sting. These pheromones are released during stinging or when an insect is smashed. Hymenoptera frequently are swallowed, and their stings can cause painful swelling in the mouth or esophagus.
• Although bee and wasp venom varies from species to species, all venom is composed primarily of proteins, peptides, and amines. Toxic components include phospholipase, histamine, bradykinin, acetylcholine, dopamine, and serotonin. In addition, mast cell degranulating (MCD) peptide and mastoparan are peptides that can cause degranulation of mast cells and result in an anaphylactoid reaction. Molecule size and the presence of protein enhance the antigen properties of venom, making it a potent activator of the immune system. Most significant reactions are mediated through true IgE allergic mechanisms that activate mast cell degranulation.
• Anaphylactoid reactions may occur. However, venom load may be sufficient to cause fatal injury without the added effects of the endogenous system. This may result from as few as 30 vespid stings or 200 honeybee stings. Since the compounds are similar in anaphylactic and toxic reactions, pathology and treatment also are similar.
• Bees and wasps sting through a modified ovipositor. They puncture the skin with a hollow stinger and then inject venom. Bees leave their barbed stinger in the skin along with its stinging apparatus, killing the bee. Vespids have smooth or less-barbed stingers and can sting more than once. Vespids are responsible for almost twice as many allergic reactions as honeybees. Retained stingers can cause granuloma formation and subsequent epidermal necrosis.
• A "killer" bee is an Africanized honeybee (Apis mellifera scutellata), the offspring of aggressive wild African honeybees and domesticated European honeybees. Aggressive defensive behavior is dominant in these offspring. This variety displays increased group defense behavior. One pheromone, isoamylacetate, has been isolated as a mediator of this activity. Africanized bees defend their hive up to a 150-yard radius, 3 times the distance of European bees.
  • As of May 2000, Africanized bees have migrated from their western-hemisphere origin in Brazil to Texas, Arizona, California, New Mexico, and Nevada, according to the US Department of Agriculture.
  • Multiple stings from these species are more common. Hymenoptera fly at only 4 mph, allowing most victims to flee after only a few stings. Overwhelming numbers of stings usually occur in young patients or in those slowed by physical limitations or intoxication.
• In addition to reaction to stings, bee venom may be encountered as a result of apiotherapy. In this Chinese treatment, ointment containing bee venom may be applied to skin or eye and result in an immunologic reaction.
• Ant stings
  • Ants account for one half of all insects. While many ant species sting, the most aggressive in the United States are imported fire ants, Solenopsis invicta. These ants fiercely guard their territory and attack intruders in large numbers, inflicting thousands of stings and bites to victims unable to escape. Fire ant venom is 95% alkaloid, which is unique among ants. A fire ant typically bites with its mandibles, then swivels its abdomen and stings repeatedly in an arc about the bite site. Their stings develop into sterile pustules and then rupture, leaving crusted wounds that may become infected secondarily. Patients have survived as many as 5000 fire ant stings. Brazilian fire ants, S invicta, have nearly eradicated native ant species in their range from Florida to Texas and north to Arkansas and South Carolina. S invicta is found in South and North America in areas where mean high temperatures are 15°C or higher.
  • Stings from other ants often closely resemble those of wasps and bees, although with less tissue destruction and less severity. Harvester ants, Pogonomyrmex species, inject venom containing a hemolysin. This sting frequently creates an ecchymotic area surrounding the sting site. Some species of field ants truly bite with the mandible and spray the acidic toxin into the wound without injecting venom. Formic acid, a component of ant venom uncommon in bee or wasp stings, is derived from the superfamily name Formicidae. Ant stings cause generalized reactions less often than stings from flying Hymenoptera.

Differential Diagnoses

Other Problems to Be Considered

Dermatosis
Foreign bodies
Intravenous drug abuse
Local infection

Workup

Laboratory Studies

• Diagnosis usually is confirmed by patient's history. In systemic reactions, laboratory studies may help evaluate organ damage caused by the reaction.
  • Complete blood count (CBC)
  • Chemistry

Procedures

• Stinger removal
  • The stinger most commonly appears as a dark barb in the skin with attached stinging apparatus.
  • People who have been stung should remove the bee stinger as quickly as possible. Removal method is not as important as rapidity because the stinging apparatus actively injects venom into the wound for 1 minute after the sting, even if the bee has been killed or knocked away from the site. Visscher and colleagues demonstrated no advantage to scraping away the stinger compared with pinching.²
  • Forceps may be needed to remove the stinger after the venom sac has been torn away.

Treatment

Prehospital Care

• Prehospital care must assess severity immediately and provide immediate appropriate treatment, because the most endangered patients die within 30 minutes of a sting.
• Local reactions can be life threatening if swelling occludes the airway. Initiate invasive measures to secure the airway if this occurs. Otherwise, the following local care measures suffice:
• Diphenhydramine limits the size of the local reaction.
• Clean wound and remove stinger if present.
• Apply ice or cool packs.
• Elevate extremity to limit edema.
• Manage generalized reactions similarly to anaphylaxis, even in the absence of shock. Check airway and ventilatory status. Treatment should include an initial intravenous (IV) bolus of 10-20 mL/kg isotonic crystalloids in addition to diphenhydramine and epinephrine.
• If the patient has not removed the stinger, it should be removed as soon as possible by the first caregiver on the scene. Delay increases venom load, so the fastest removal technique is the best. Pinching and traction is an acceptable technique.

Emergency Department Care

• Corticosteroids and cimetidine may be given IV; vasopressors such as dopamine can be used to provide vascular support.
• Patients developing respiratory arrest require ventilatory support.
• Blood products may be required in the event of disseminated intravascular coagulation (DIC).

Consultations

• Refer all patients with generalized reactions to an allergist as soon as possible, because risk of fatal reaction is inversely related to length of time since the last sting.

Medication

Medications used to treat Hymenoptera stings include antihistamines (H1, H2), steroids, alpha- and beta-receptor agonists, and bronchodilators.

Antihistamines

These drugs directly block effects of some venom and effects of endogenously released histamine.

Diphenhydramine (Benadryl)

DOC for all stings, is an H1 and partial H2 receptor blocker used for symptomatic relief of allergic symptoms caused by histamine released in response to allergens.

Dosing

Adult

50-75 mg PO/IM q4h; IV may be administered slowly in emergency situations

Pediatric

1-2 mg/kg PO/IM

Interactions

Potentiates effect of CNS depressants; due to alcohol content, do not give syrup dosage form to patient taking medications that can cause disulfiramlike reactions

Contraindications

Documented hypersensitivity; MAOIs

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, and urinary tract obstruction

Cimetidine (Tagamet)

Indicated for systemic reaction that does not respond completely to diphenhydramine, or when severity indicates need for maximal treatment.

Dosing

Adult

300-800 mg IV q6h

Pediatric

5 mg/kg IV q6h

Interactions

Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Older patients may experience confusional states; may cause impotence and gynecomastia in young males due to weak antiandrogen properties; may increase levels of many drugs; consider adjusting dosage or discontinuing treatment if renal function changes occur during therapy

Bronchodilators

Epinephrine causes vasoconstriction, bronchodilation, and increased cardiac output. The effects of albuterol and theophylline are more focused on bronchodilation.

Epinephrine (Epi-Pen)

DOC for systemic reactions, has alpha-agonist effects that increase peripheral vascular resistance and reverse peripheral vasodilation, systemic hypotension, and vascular permeability. Conversely, beta-agonist activity of epinephrine produces bronchodilation, chronotropic cardiac activity, and positive inotropic effects. Epinephrine may be self-administered through auto-injectors.

Dosing

Adult

0.2-1 mg IV/SC

Pediatric

0.01-0.1 mg/kg IV/SC

Interactions

Increases the toxicity of beta- and alpha-blocking agents and of halogenated inhalational anesthetics

Contraindications

Documented hypersensitivity; cardiac arrhythmias; angle-closure glaucoma; avoid coadministration with local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of the tissue; do not use during labor as it may delay the second stage of labor

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in older persons and in patients with diabetes mellitus, hyperthyroidism, prostatic hypertrophy, hypertension, cardiovascular disease, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias

Albuterol (Proventil, Ventolin)

Adjunctive treatment for bronchospasm given by nebulization, it is a beta-agonist useful to treat bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by action on beta2-receptors and has little effect on cardiac muscle contractility.

Dosing

Adult

2.5 mg by nebulization in 3 cc saline
May be repeated q15min or administered continuously in severe cases

Pediatric

0.1 mg/kg by nebulization in 3 mL saline, not to exceed 2.5 mg
May be repeated q15min or administered continuously in severe cases

Interactions

Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; cardiovascular effects may increase with MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents

Contraindications

Documented hypersensitivity; adrenergic amines, or related products; history of tachycardia

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders

Theophylline (Aminophylline)

Used to relieve bronchospasm in resistant cases, acts to decrease muscle tone in both small and large airways in lungs, thus increasing ventilation.
Efficacy managing bronchodilation may be due to its potentiation of exogenous catecholamines, stimulation of endogenous catecholamine release, and diaphragmatic muscular relaxation. Effects as a bronchodilator usually are seen at levels considered to be toxic (>20 mg/dL).

Dosing

Adult

Loading dose: 5-6 mg/kg IV over 30 min, then 0.9 mg/h
Adjust rate as tolerated to achieve therapeutic levels of 10-20 mcg/mL

Pediatric

Administer as in adults

Interactions

Aminoglutethimide, barbiturates, carbamazepine, ketoconazole, loop diuretics, charcoal, hydantoins, phenobarbital, phenytoin, rifampin, isoniazid, and sympathomimetics may decrease effects of theophylline; theophylline effects may increase with allopurinol, beta-blockers, ciprofloxacin, corticosteroids, disulfiram, quinolones, thyroid hormones, ephedrine, carbamazepine, cimetidine, erythromycin, macrolides, propranolol, and interferon

Contraindications

Documented hypersensitivity; uncontrolled arrhythmias, peptic ulcers, hyperthyroidism, uncontrolled seizure disorders

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in peptic ulcer, hypertension, tachyarrhythmias, hyperthyroidism, and compromised cardiac function; do not inject IV solution faster than 25 mg/min; patients diagnosed with pulmonary edema or liver dysfunction are at increased risk of toxicity because of reduced drug clearance

Corticosteroids

These drugs act to stabilize lymphocytes and to reduce release of endogenous vasoactive compounds.

Methylprednisolone (Solu-Medrol, Depo-Medrol)

Indicated in all cases of generalized reaction unless contraindications exist. Useful to treat inflammatory and allergic reactions. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.

Dosing

Adult

0.25-1 g IV over 30 min q6h

Pediatric

0.2-2 mg/kg IV over 30 min q6h

Interactions

Coadministration with digoxin may increase digitalis toxicity secondary to hypokalemia; estrogens may increase levels of methylprednisolone; phenobarbital, phenytoin and rifampin may decrease levels of methylprednisolone (adjust dose); monitor patients for hypokalemia when taking medication concurrently with diuretics

Contraindications

Documented hypersensitivity; viral, fungal, or tubercular skin infections

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, and infections are possible complications of glucocorticoid use

Follow-up

Further Inpatient Care

• Consider further inpatient care for all patients with life-threatening reactions.
• Observe for sufficient duration to ensure symptoms do not rebound after initial treatment. Rebound phenomena may occur up to 12 hours after sting.
• Respiratory and circulatory support may be needed if secondary organ damage has occurred.

Further Outpatient Care

• Refer all patients with generalized reactions for allergy testing and desensitization, if indicated.
• Provide means to self-administer epinephrine and diphenhydramine to all patients with generalized reactions, and advise them to wear medic alert bracelets.
• Continue treatment with steroids in the ED for 3-5 days.
• Continue administering antihistamines for at least 24 hours continuous dosing.
• Cool sting sites for 12 hours.
• Keep extremities with stings elevated for 12 hours when development of edema may present difficulties.

Deterrence/Prevention

• Avoiding stings is vitally important for persons who are hypersensitive. Whenever these patients are out of doors, they should adhere to the following suggestions:
  • Avoid using perfumes or hygiene products that include perfumes as these may attract flying Hymenoptera.
  • Avoid wearing bright colors.
  • Avoid known hive or nest locations.
  • Do not use noisy equipment such as lawn mowers, edgers, or blowers within 50 yards of beehives or 150 yards of Africanized bee colonies.
  • Do not flail arms when confronted by bees or wasps because smashing one often incites others to sting.

Complications

• Sting sites may become infected. Infection is more common in fire ant stings because they frequently are multiple; stings vesiculate and then ulcerate, leaving pruritic open wounds.
• Rebound anaphylaxis may occur in patients with generalized reactions as antihistamine and alpha-agonist levels subside after treatment.
• Anaphylaxis may occur in susceptible patients from exposure to other insect-related material, including honey and apiotherapy.
• Serum-sickness-type reactions may occur up to 14 days after a sting.
• Myocardial infarction, renal failure, DIC, and cerebral edema may occur after a bee sting.
  • One case report documents transient inferior ST-segment elevation consistent with myocardial ischemia after a single wasp sting in a 58-year-old man.³
  • In a retrospective analysis of medical records from 1985-2007, 7 of 45 pediatric patients were noted to have developed acute renal failure after a wasp sting.⁴
• Peripheral nerve block may occur if sting is near the path of a nerve.

Prognosis

• Most stings resolve with no residual complaints.
• Large local reactions do not predispose patients to generalized reactions in the future.
• Less severe generalized reactions precede most fatal reactions.

Patient Education

• Educate all patients on how to avoid stings.
• For excellent patient education resources, visit eMedicine's Bee and Wasp Stings Center, Environmental Exposures and Injuries Center, Allergy Center, and Allergic Reaction and Anaphylactic Shock Center. Also, see eMedicine's patient education articles Bee and Wasp Stings and Severe Allergic Reaction (Anaphylactic Shock).
• For related information, see Medscape's Allergy Resource Center.

Miscellaneous

Medicolegal Pitfalls

• Failure to remove stinger may produce infection or granulomatous reaction.
• Failure to observe patient after treating a generalized reaction may result in unobserved rebound.
• Failure to provide means of self-treatment in those with demonstrated tendency to generalized reactions may result in unnecessary future reactions. Refer these patients to an allergist for assessment.

Special Concerns

• Infants are likely to sustain numerous fire ant stings, and they do not refrain from scratching open wounds, increasing the frequency of secondary infection. Some authorities recommend prophylactic antibiotics for children with more than 30 fire ant stings.

Multimedia

Media file 1: Two fire ant stings that are 24 hours old (Randy Park, MD)

Media file 2: A paper wasp (Randy Park, MD)

Media file 3: A paper wasp (Randy Park, MD)

Media file 4: A paper wasp (Randy Park, MD)

References

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Keywords

bee stings, yellow jacket sting, hornet sting, ant stings, wasp stings, vespid stings, bee envenomations, Hymenoptera envenomations, ant envenomations, wasp envenomations, vespid envenomations, Apis species, wasps, ants, severe anaphylactoid reactions, angioedema, respiratoryarrest, fatal allergic reactions, urticaria, confluent red rash

syncope, anxiety, confusion, wheezing, tachypnea, hypotension, laryngoedema, lingular edema, uvular edema, delirium, shock, honeybee stings, Africanized honeybee, , isoamylacetate, pheromone, apiotherapy, fire ants, , fire ant venom, Harvester ants, species

Contributor Information and Disclosures

Author

Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Hemant H Vankawala, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital
Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM, Associate Clinical Professor of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School; Medical Director, WeCare Med, Inc
Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

Clinical guidelines

Stinging insect hypersensitivity: a practice parameter update. Moffitt JE, Golden DB, Reisman RE, Lee R, Nicklas R, Freeman T, deShazo R, Tracy J, Bernstein IL, Blessing-Moore J, Khan DA, Lang DM, Portnoy JM, Schuller DE, Spector SL, Tilles SA. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol 2004 Oct;114(4):869-86.

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