ALLERGIA a VELENO di IMENOTTERI - Emilia-Romagna. E. MEUCCI.pdf · ALLERGIA a VELENO di IMENOTTERI...
Transcript of ALLERGIA a VELENO di IMENOTTERI - Emilia-Romagna. E. MEUCCI.pdf · ALLERGIA a VELENO di IMENOTTERI...
ALLERGIA a VELENO di IMENOTTERI
Elisa Meucci
S.Capretti
F. Fassio
MCL. Iorno
A. Radice
D. Macchia
SOS Allergologia Immunologia Clinica
Nuovo San Giovanni di Dio (Firenze)
SOC Allergologia Immunologia Toscana Centro
Dipartimento Specialistiche Mediche
The frequency of anaphylaxis has been estimated to be 50–2000
episodes per 100,000 persons, with a lifetime prevalence of 0.05%–
2.0%.
Attacks of anaphylaxis lead to the death of 0.65%–2.0% of sufferers
●Hymenoptera stings are among the most
frequent causes of anaphylaxis
● responsible for an annual fatality rate in Europe
of approximatively 200 individuals
Incidence of anaphylaxis with circulatory symptoms: a
study over a 3-year period comprising 940,000
inhabitants of the Swiss Canton Bern.
Helbling A, Hurni T, Mueller UR, Pichler WJ.
Clin Exp Allergy. 2004
Clin Exp Allergy 2009
•Older age
•Insect type (honey bee, european hornet)
•Pre-existing disease: cardiovascolar disease, asthma
•Drugs: particularly b-blockers,
angiontensin-converting enzyme inhibitors
•Sting site (head)
•Mast cell disease, elevated baseline serum tryptase
concentration
Comparison of the robustness and functionality
of three adrenaline auto-injectors
●The Adrenaline Auto-injectors (AAI) currently available in Europe Jext®,
EpiPen®, and Anapen® are designed to deliver a single dose of 0.15 mg
(pediatric) or 0.3 mg (adult) adrenaline in a sterile solutio im into the vastus
lateralis muscle of the thigh.
Schwirtzs J of Asthma and Allergy 2012
• ACTIVATION FORCE
• TEMPO D’INIEZIONE e VOLUME
• ESPOSIZIONE DELL’ AGO
• PERFORMACE DELL ‘ AAI in GELATINA
• DISTRIBUZIONE nella GELATINA
Comparison of the robustness and functionality
of three adrenaline auto-injectors
Schwirtzs J of Asthma and Allergy 2012
MEAN exposed needle:
15,6 mm jext
15,02 mm epipen
7,6 mm anapen
Allergy 2016
QUANDO PRESCRIVERE 2 AUTOINIETTORI?
• Mastocitosi
• Precedente episodio near-fatal
• Precedente necessità di più di una dose di
adrenalina
• Obesità
• Lontananza da un punto di soccorso
PRIMO LIVELLO•Anamnesi•Test cutanei•IgE specifiche sieriche•TriptasiSECONDO LIVELLO•CRD•RAST inibizioneALTRI TEST: BAT, immunoblotting, liberazione d’istamina
Diagnosi di allergia al veleno di Imenotteri
CRD in hymenoptera venom allergy
EAACI Molecular Allergology User’s Guide 2016
Molecular diagnostics with recombinant marker allergens is able to exclude ‘false-positive’ test results due to IgE directed against CCDs or homologous allergens present in venom extracts and to uncover IgE sensitizations to allergens that are underrepresented, labile, degraded, or masked in venom extracts.
Double sensitization• the majority of crossreactivities between honeybee and vespid venom can be attributed to
clinically irrelevant IgE antibodies that are directed against cross-reactive
carbohydrate determinants (CCDs)
This is of particular importance, as most Hymenoptera venom allergens are
glycoproteins with one or more of such carbohydrate structures
In insects the relevant CCD epitope is defined by an alpha-1,3-linked fucose residue at the
innermost N-acetylglucosamine • highly immunogenic because they are not present in
mammals and can induce the production of specific
IgG and IgE antibodies.
• No CLINICAL RELEVANCE
Aeberhard et al, J Investig Allergol Clin Immunol 2017
Specific Immunotherapy in Hymenoptera Venom Allergy and
concomitant Malignancies. A retrospective follow-up focusing on
efficacy and safety.
In case of concomitant malignancies VIT has been considered contraindicated
Wohrl et al Int Arch Allergy Immunol 2011
EAACI position paper 2015
• 42 of a total of 1,495 patients with VIT were diagnosed with cancer either before
VIT (25 subjects), during VIT (16 subjects) or after VIT (one subject)
• overall incidence of cancer was 1.1 %. This number of affected patients is lower
than in the general Swiss population (2.2 %).
• Among 25 patients with known malignancies at the start of VIT, it results safe in
stable cancer disease
• It is safe to resume VIT after cancer treatment has been conducted.
• The impact of the cancer, or its treatment, seems not to reduce the immunologic
response to VIT
ESTRATTI acquosi, depot, purificati
DOSE 50-100-200 mcg
BUILD-UP tradizionale, cluster, rush, ultrarush
TIMING della SOMMIN. primo anno ogni 4 sett.
secondo anno ogni 6
terzo anno ogni 8
quarto anno ogni 10
dal quinto in poi ogni 12
Venom immunotherapy (VIT) in Hymenoptera
venom allergy is an established treatment with
an efficacy rate of 75-80 % in bee venom and
over 90 % in Vespula venom allergic patients
EAACI Interest Group on Insect Venom Hypersensitivity.
Prevention and treatment of Hymenoptera venom allergy:
guidelines for clinical practice. Allergy 2005
The anxiety that some patients feel about LLRs may be
initiated by friends and even physicians concerned about
the risk of fatal systemic reactions to subsequent stings
(‘the next one will kill you’).
2016
the risk of anaphylaxis 5–15% from several studies,
but all of them studied very small numbers of patients and
most of them were retrospective.
epinephrine prescription to patients with LLRs gives
patients the impression that there is significant risk of
anaphylaxis, even when they are told that the risk is
‘minimal’. Prescription of epinephrine is not benign and is
associated with impaired quality of life
Triptasi persistentemente elevata
Diagnosi : biospsia cutanea+o - BOM
Prurito, flushing, orticaria
Anafilassi (imenotteri/ farmaci/alimenti)
Sincope/palpitazioni
Osteoporosi, fratture vertebrali
Cefalea, difficoltà di concentrazione Depressione, insonnia
Diarrea, crampi addominali, gastrite
Stimoli fisici- calore- freddo- pressione- sfregamentoFattori emozionali- stress- ansiaFarmaci
- acido acetilsalicilico- antinfiammatori non steroidei- morfina e rilassanti muscolari utilizzati nell’anestesia generale, anestetici locali- beta-blocccanti, alfa-adrenergici e antagonisti dei recettori colinergici- polimixina-B, anfotericina-B- interferon-alfa- molecole ad alto peso molecolare come il destranoMezzi di contrasto iodati
Punture di insetti (imenotteri, ditteri)AlcoolAlimenti Esami endoscopici/ Interventi chirurgici
Fino all’8% dei pazzienti con grave reazione allergica a puntura d’imenottero è
affetta da mastocitosi
Alcuni pazienti vengono dignosticati soltanto a causa della gravità della reazione
dopo puntura di imenotteri
Questi pazienti hanno della caratteristiche diverse dagli altri pazienti con mastocitosi
e ci si chiede se sia un’entità patologica a se stante.