Successful venom immunotherapy to paper wasp, in IgE-venom negative patient

Abstract

Palabras clave: Inmunoterapia frente a veneno. Veneno de avispa. Trastornos autoinmunológicos. Venom immunotherapy (VIT) is the only highly effective way of treating patients with hymenoptera venom allergy (HVA). The most serious anaphylactic symptoms of HVA (HVA-SYS IVo) are life-threatening, thus making their occurrence an unconditional recommendation for VIT. Yet, VIT is contraindicated in immune-mediated inflammatory diseases. We present the case of a 55-year-old woman with autoinflammatory neurological disease (initially diagnosed with relapsing remitting multiple sclerosis) who received VIT following an anaphylactic reaction (SYS-IVo) to wasp sting (Vespula germanica). Allergy tests showed the presence of specific IgE antibodies to wasp venom (intradermal test at 0.001 µg/mL, 12×12 mm; sIgE class 2). The basal serum tryptase concentration was normal. Her past medical history included gastrointestinal reflux, mild gastritis, allergy to ketoprofen and metamizole sodium, and seronegative spondyloarthropathy. At the age of 50, she was diagnosed with remitting-relapsing multiple sclerosis. Her first symptoms of neurological damage were mild facial weakness, mild instability with the eyes closed in the Romberg test, and clumsy movements of the left hand. Magnetic resonance imaging (MRI) was performed twice and revealed multiple hyperintense areas that were considered demyelinating lesions. The cerebrospinal fluid study showed intrathecal production of immunoglobulins (Tibbling-Link IgG index, 1.75 [normal range, 0.2-0.85]). Visual evoked potentials were normal. Lyme disease was excluded. The patient was treated with intravenous methylprednisolone (Solu-Medrol, 1000 mg/d over 5 days) during 3 exacerbations of the disease. Progression in her disability was measured using the Kurtzke Expanded Disability Status Scale (EDSS). Her initial EDSS was 1.5, which rose to 4.0 after the last exacerbation of the disease. The patient met the clinical and immunological criteria for VIT. Another reason in support of the decision to administer VIT was the patient's physical disability, which might have hindered attempts to avoid a sting, especially given that she lives in an area with high exposure to stinging insects. The decision to start VIT was made despite the hitherto accepted belief that autoimmunological diseases constitute a contraindication to immunotherapy. At the time the patient qualified for VIT, her condition was stable, with no new active neurological symptoms. No complications were recorded during the induction phase (ultrarush; Pharmalgen, ALK-Abelló) and a complete 5-year course of VIT. There were no local or systemic allergic reactions. Neurological symptoms did not intensify, and no new symptoms appeared. The patient did not experience exacerbation of her neurological disease; the EDSS score remained unchanged. The findings in subsequent MRI examinations of the brain were stable, with no new lesions. The MRI revealed no lesions in the temporal lobes or posterior fossa structures and no juxtacortical lesions (...

Current Advances in Immunological Studies on the Vespidae Venom Antigen 5: Therapeutic and Prophylaxis to Hypersensitivity Responses

“…Immunotherapy with venom extracts from social insects is highly effective and widely used in the treatment of patients with a history of anaphylaxis [ 87 ]. Specific immunotherapy is the only treatment for type I allergies and is based on the accurate allergy history of the individual and the results of skin and RAST (Radioallergosorbent) diagnoses, which confirm the presence of IgE [ 99 , 100 ]. The risk of inefficiency of specific immunotherapy can be associated with de novo sensitization to new allergenic proteins (or cross-reacting allergens) to which patient had not presented any reaction [ 19 ].…”