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Although its part of the business, few of us actually look forward to being stung. As
beekeepers we need to know about the various reactions to bee stings and be responsible to
ourselves, family, neighbors and friends in regard to bee stings. I hope this article will serve
some of those purposes and be informative to both the beginner beekeeper and the most expe-
rienced scientist. The first part will cover insects that sting, honey bee stings in particular, bee
venom biochemistry, precautions and sting prevention, the management of beekeeping
emergencies, and basic immunology and allergy. The second part will cover sting reaction
types and treatments, allergy testing and desensitization results, and specific recommenda-
tions for beekeepers.
T
he order Hymenoptera includes bees and carpenter bees, can inflict a
ants, bees, hornets, and wasps, sting, the risk of an allergic response to
many of which inflict stings (Table their venom is low because they are both
unaggressive and the amount of venom
they inject is low. More aggressive, prim-
itively social paper wasps, yellow jackets,
bald-faced hornets and European hornets
from the Family Vespidae (Figures 1 4)
as opposed to eusocial honey bee work-
ers from the Family Apidae can sting
more than once. If the flying stinging
insect that inflicts a sting is unidentified,
most often (unless the sting is still present
Figure 1. Wasp (Polistes sp.), Buddy Figure 2. Yellow Jacket (Vespula vul-
Marterre, MD garis), courtesy of Jarmo Holopainen
Table 1
Hymenoptera Species with Venoms for Immunotherapy
Vespidae Wasps
Vespinae
Vespula ground-nesting yellow jackets
Dolichovespula aerial yellow jackets
Vespa hornets
Polistinae
Polistes paper wasps
Formicidae Ants
Myrmicinae
Solinopsis fire ants
Apidae Bees
Apinae
Apis honey bees Figure 4. European Hornet (Vespa
crabro), Buddy Marterre, MD
marterre article bee stings 1.qxp 6/14/2006 3:29 PM Page 2
B as well as antigen 5, which honey bee belong to the body (self), but distinguish
venom does not contain, however. The Table 4 these from proteins that dont belong (non-
proteins in the venoms of individual yel- Management of Emergencies self). The specialized white blood cells in
low jacket and hornet species (subfamily the immune system that do this are called
Vespinae) are quite similar. This leads to Close the hive if you can lymphocytes. Lymphocytes utilize com-
a lot of cross reactivity in the human Cover up plex protein receptors on their surface to
immune response to them. Thus, venoms Kill any bees inside your veil recognize self and non-self and they gener-
for testing hypersensitivity and Get your smoker ate two integrated responses to foreign
immunotherapy desensitization are typi- Walk at least 20 yards away into brush proteins (such as those from bee venom).
cally available separately for honey bees, (evergreens) One effector arm of the immune response
wasps, and mixed vespids. Return when calm (20 minutes) is the production of antibodies and the
other is the production of other controlling
Precautions and sting prevention away into some brush. Evergreens are par- and effector lymphocytes.
Good technique can reduce the number ticularly good at distracting bees. Walk. Do Antibodies are produced by B lympho-
of bee stings you receive (Table 3). not run (unless you can run a 5 minute mile)! cytes and are large complex proteins called
Realize that the mood of the hive can be Dont swat bees. Dont return to the scene of immunoglobulins (Ig). Immunoglobulins
affected by many things, such as season, the crime until you and the bees have calmed or antibodies have a hypervariable region
weather, and many factors that may only down (this takes about 10 or 20 minutes for that fits around a small piece of a foreign
be apparent to the bees. A long time ago I the bees I cant say for you)! protein (antigen) like a lock fits over a key.
gave up trying to predict the mood of the If a bee gets inside your veil, kill it The fit is even more specific than a key
five females I live with, much less the before it can sting your face. If you dont and lock, however, because it is in three
50,000 females in a bee hive! Therefore, have a veil on (heaven forbid) and bees are dimensions and also includes charge affin-
dont assume that a given hive will be flying into your face, close your eyes and ity (areas of negative charge on the antigen
gentle just because it had a good tempera- walk away (and get your veil). If you have line up with areas of positive charge in the
ment the last time you inspected it. Also, a bunch of bees inside your veil (more than cleft of the antibody). There are many dif-
if you are a suburban beekeeper (like me), two or three), take it off, cover your face ferent classes of antibodies, but the pri-
only keep very gentle bees near your and let them sting your hands. And remem- mary class in the bloodstream that is
house. And inquire as to your neighbors ber, every sting leaves you marked for involved with a normal immune response
possible venom allergies. more! is IgG and the class that is involved with
Work hives on warm, sunny, calm days. an allergic or hypersensitivity response is
Immunology and allergy IgE.
Table 3 The human immune system is highly The controlling cells of the immune
Precautions and Sting Prevention complex. Its basic function is to recognize response are called T lymphocytes. They
and destroy foreign tissue (like bacteria or recognize the foreign antigen with recep-
Wear white viral-infected cells). In order to do this, it tors on their surface (very much like anti-
and ALWAYS WEAR YOUR VEIL must not only recognize proteins that bodies) and can induce B cells to make
Avoid using perfumes and eating bananas
USE SMOKE judiciously
Work slowly and deliberately
Remove and smoke stings ASAP
Wash your bee suit and gloves frequently
Management of emergencies
Its better to be prepared for a major bat-
tle and not have one than to only prepare
for a minor skirmish and experience a
major war. What do you do if you drop or
knock over a hive and there are more
angry, stinging bees than you ever thought
possible coming at you? Table 4: Close the
hive if you can (easily). Cover up. Get
your smoker and smoke yourself (if its
still lit). Calmly walk at least 20 yards Figure 9. Diagram of Allergic Immune Response, by Rachel Alexandra Marterre
marterre article bee stings 1.qxp 6/14/2006 3:29 PM Page 4
specific antibodies to the antigen. Their and released by the mast cells are primari-
response may include recruiting other cells
Table 5 ly responsible for the late phase of anaphy-
Mast Cell Granule Contents and Products
to destroy it (using chemical messengers laxis. They attract other effector cells of
called cytokines similar to pheromones Histamine, Serotonin allergies, like eosinophils, basophils, and
in a bee hive) or by directly attacking the Enzymes (that destroy proteins or initiate neutrophils (which significantly contribute
foreign antigen themselves. In both the cascades) to allergic responses). Once these process-
case of antibody production by B cells and Heparin (anticoagulant) es get initiated, they can snow-ball in a
T lymphocyte generation, memory cells Eosinophil Chemotactic Factor of hurry and cause a lot of problems very
(both B and T) are generated that can then Anaphylaxis quickly. Again, if the allergic reaction
recognize the foreign antigen decades Neutrophil Chemotactic Factor becomes systemic (throughout the entire
later. This is how immunity to a virus or Leukotrienes body), it is called anaphylaxis.
bacteria or venomous sting can last a life- Prostaglandins Thats enough science for one article.
time, even though exposure to it may have Cytokines (which recruit other inflam- In part two, well discuss sting reaction
been years before or even in childhood. matory cells) types and treatments, allergy testing
The effector cells that are recruited by and desensitization results, and specific
the T cells and the antibody classes that B proteins or initiate other cascades), heparin recommendations for beekeepers.
cells make differ with different people, (an anticoagulant), and chemicals that
even in response to the same foreign anti- attract eosinophils (another allergic effec- About the author
gen. The cytokine messenger profiles (that tor cell) (Table 5). These primary media- Ive had allergies all my life. I became
recruit other effector cells) also differ from tors are released within minutes and their very interested in bees while I was in col-
individual to individual. Thus, some indi- effects on the human body begin very lege at Virginia Tech. But the beekeeping
viduals may make allergic IgE antibodies quickly. Histamine dilates blood vessels, course I wanted to take interfered with bio-
to bee venom antigens even though most makes them leaky, and activates the chemistry lab (my major), so instead I took
people make non-allergic IgG antibodies. endothelium (or lining of the capillaries). graduate courses in immunology. After
An allergic response to a venom antigen This leads to local edema (swelling), medical school and a general surgery resi-
(now called an allergen) is also quite com- warmth, redness, and the attraction of dency, I did a fellowship in and then prac-
plex. It begins with IgE antibodies and other inflammatory cells to the site. In ticed transplant surgery. So while I learned
mast cells. Mast cells are already present large amounts, it can drop blood pressure, and practiced more immunology (by trans-
in the sting site (Figure 8). Mast cell sur- and cause rapid swelling of the airway planting foreign organs), my personal
faces are loaded with IgE antibodies that (leading to stridor or an inability to experience with bee stings was still lack-
may react with many different types of breathe) and constrict bronchial tubes ing. After my fellowship, I married an
antigens or allergens. After venom is (causing an asthmatic attack). Histamine experienced intensive care nurse, who is
injected into the skin, at least two IgE anti- also irritates nerve endings (leading to now a certified pulmonary-allergy nurse.
bodies on the surface of a mast cell each itching or pain). Then, I finally became a beekeeper and am
react with the venom allergen, causing the Upon activation, mast cells also begin to now a Master Beekeeper in North
immediate release of preformed sub- synthesize secondary chemicals which Carolina. I have large local reactions to bee
stances in the granules of the mast cell, as have more delayed effects including stings and have experienced quite a few
well as the production of other new sub- prostaglandins, leukotrienes, and cy- of those! Being concerned about my risk of
stances. Refer to the Figure 9 for a basic tokines. Some of these secondary chemi- more serious reactions, I went back to the
diagram of an allergic immune response. cals (particularly the cytokines) are immunology and allergy journals. Then,
And recall, the mast cell degranulating responsible for the late phase of allergy, last year, I had an anaphylactic reaction
peptide in bee venom can cause this reac- which typically begins 2 4 hours after the (fortunately not to bee stings, but to
tion all by itself even without a typical insult. The prostaglandins and leukotrienes salmon which I had eaten many times
allergic response! With just a few stings, like histamine also cause bronchial before)! Thus, I am a doctor, a beekeeper,
mast cell degranulating peptides effects constriction, dilation of blood vessels and and a patient. In addition to all the photo
are only local, but with hundreds of stings leaky capillaries, but their onset is hours credits, Id also like to thank two excellent
the venom dose can cause toxic effects. later and their effects more long-lasting. allergists for their review of this article:
Once activated, mast cells release a lot Aspirin can actually exacerbate these Aneysa Sane, MD from Wake Forest
of very potent preformed chemicals from effects by causing more leukotrienes and University Medical Center, and Larry
their granules immediately, including his- fewer prostaglandins to be produced by the Williams, MD from Duke University
tamine, proteases (enzymes that destroy mast cells. The cytokines which are made Medical Center.
Marterre article Bee Stings part 2.qxp 7/13/2006 2:42 PM Page 1
Although its part of the business, few of us actually look forward to being stung. As beekeepers
we need to know about the various reactions to bee stings and be responsible to ourselves,
family, neighbors and friends in regard to bee stings. I hope this article will serve some of those
purposes and be informative to both the beginner beekeeper and the most experienced. The first
part of this article covered insects that sting, honey bee stings in particular, basic bee venom
biochemistry, precautions and sting prevention, management of beekeeping emergencies, and
basic immunology and allergy. This second part will cover sting reactions and types, sting
treatments, allergy testing and desensitization results, and specific beekeeper recommendations.
Sting reaction types and treatments gories: 1) venom removal or suction area (sometimes the entire extremity) than
T
he NORMAL reaction to a ven- devices, 2) bases such as urea, ammonia, a normal reaction (Figure 12). It starts as
omous insect sting is one of local and baking soda (to neutralize the acidity pain and a wheal (a several centimeter
pain and up to a few centimeters of of the venom), 3) hygroscopic agents (to swollen itch). A few hours after the sting
edema (swelling) that resolves in a few draw out the fluid) such as honey, mud, more redness, edema (swelling), and itch-
hours to a few days (Figure 10). Any sting and various pastes, and 4) lotions to ing develop. Over 12 48 hours, the area
can become secondarily infected, but for- decrease the itch such as calamine lotion, can become quite swollen, painful, and
tunately, this is fairly uncommon. Anusol, and Benadryl cream. All topical may also have some associated ecchymo-
Parenthetically, fire ant stings form a treatments require immediate application, sis (flecks of purple or red from a bruise
pseudopustule (Figure 11). These blisters so they are probably best used in non-bee- within the skin itself). The swelling gener-
may last for 10 days and should not be keeping situations. And as far as local ally begins to resolve after two days, but
confused with a true infection (pustule). applications for sting prevention is con- the site may remain tender (and continue to
The pseudopustules from fire ant stings cerned, DEET-containing bug sprays do itch) for a few more days. The total reac-
should be left intact (not unroofed or surgi- nothing to deter vespid stings. Normal tion lasts 4 7 days. Large locals around
cally drained). reactions are not an allergic response, and the face and mouth or on the hands may
The first treatment of a normal reac- allergy testing and desensitization are not cause temporary disability. The large local
tion is to quickly remove the sting and indicated after these. is IgE-mediated, and therefore is an aller-
smoke the area. Many local remedies have A LARGE LOCAL reaction is confined gic response.
been suggested for the treatment of bee to the general area of the sting, but over 24 Treatment of a large local includes ice
stings. These generally fall into 4 cate- 48 hours it develops into a much larger and elevation. Taking an anti-histamine or
Eich-Wanger and Muller reported on 69 Sane, MD from Wake Forest University gy to insect stings in children, with and
beekeepers with an allergic reaction to bee Medical Center, and Larry Williams, MD without venom immunotherapy. The
stings, 42 of whom had had a severe reaction. from Duke University Medical Center. New England Journal of Medicine.
Thirty-one of the 69 allergic beekeepers con- 351(7):668-674.
tinued beekeeping. Twenty-two of the 31, Selected Bibliography Golden DBK, Kwiterovich KA, Kagey-
who continued beekeeping, received venom Annila IT, Annila PA, and P Morsky. Sobotka A, Valentine MD, and LM
immunotherapy and none of them developed 1997. Risk assessment in determining Lichtenstein. 1996. Discontinuing
a systemic reaction to re-stings, whereas 4 of systemic reactivity to honeybee stings in venom immunotherapy: Outcome after
the 9 who insisted on beekeeping without beekeepers. Annals of Allergy, Asthma, five years. Journal of Allergy and
immunotherapy did. Interestingly, the 22 and Immunology. 78(5):473-477. Clinical Immunology. 97(2):579-587.
allergic beekeepers, who received allergy Annila IT, Karjalainen ES, Annila PA, Goodman L. 2003. Form and Function in
shots and successfully returned to beekeep- and PA Kuusisto. 1996. Bee and wasp the Honey Bee. International Bee
ing, then gave themselves one or two stings sting reactions in current beekeepers. Research Association, Cardiff, UK.
per week during the active season and one Annals of Allergy, Asthma, and Lerch E, and UR Muller. 1998. Long-
sting per month during the winter (as contin- Immunology. 77(5):423-427. Term protection after stopping venom
ued self-administered maintenance therapy). Annila I, Saarinen JV, Nieminen MM, immunotherapy: Results of re-stings in
Moilanen E, Hahtola P, and IT 200 patients. Journal of Allergy and
About the author Harvim. 2000. Bee venom induces high Clinical Immunology. 101(5):606-612.
Ive had allergies all my life. I became histamine or high leukotriene C4 release Levine MI, Lockey RF, eds. 2003.
very interested in bees while I was in col- in skin of sensitized beekeepers. Journal Monograph on Insect Allergy, 4th ed,
lege at Virginia Tech. But the beekeeping of Investigational Allergology and American Academy of Asthma, Allergy
course I wanted to take interfered with bio- Clinical Immunology. 10(4):223-228. and Immunology, Pittsburgh, PA: David
chemistry lab (my major), so instead I took Arcieri ES, Franca ET, de Oliveria HB, Lambert Associates.
graduate courses in immunology. After De Abreu Ferreira L, Ferreira MA, Reisman RE. 1992. Natural history of
medical school and a general surgery resi- and FJ Rocha. 2002. Ocular lesions insect sting allergy: Relation to severity
dency, I did a fellowship in and then prac- arising after stings by hymenopteran of symptoms of initial sting anaphylaxis
ticed transplant surgery. So while I learned insects. Cornea. 21(3):238-330. to re-sting reactions. Journal of Allergy
and practiced more immunology (by trans- Bousquet J, Menardo J-L, Aznar R, and Clinical Immunology. 90(3 Pt
planting foreign organs), my personal Robinet-Levy M, and F-B Michel. 1):335-339.
experience with bee stings was still lack- 1984. Clinical and immunologic survey Schmidt, JO. 1992. Allergy to Venomous
ing. After my fellowship, I married an in beekeepers in relation to their sensiti- Insects. In The Hive and the Honey Bee.
experienced intensive care nurse, who is zation. Journal of Allergy and Clinical JM Graham, ed. Dadant & Sons,
now a certified pulmonary-allergy nurse. Immunology. 73(3):332-340. Hamilton, IL, pp.1209-1269.
Then, I finally became a beekeeper and am Davis CF. 2004. The Honey Bee Inside van Halteren HK, van der Linden P-
now a Master Beekeeper in North Out. Bee Craft Limited, Stoneleigh, UK. WG, Burgers SA, and AKM
Carolina. I have large local reactions to bee Eich-Wanger C, and UR Muller. 1998. Bartelink. 1996. Hymenoptera sting
stings and have experienced quite a few Bee sting allergy in beekeepers. Clinical challenge of 348 patients: Relation to
of those! Being concerned about my risk of and Experimental Allergy. 28(10):1292- subsequent field stings. Journal of
more serious reactions, I went back to the 1298. Allergy and Clinical Immunology.
immunology and allergy journals. Then, Golden DBK, Kagey-Sobotka A, and LM 97(5):1058-1063.
last year, I had an anaphylactic reaction Lichtenstein. 2000. Survey of patients Vetter RS, Visscher PK, and S
(fortunately not to bee stings, but to salmon after discontinuing venom immunothera- Camazine. 1999. Mass envenomations
which I had eaten many times before)! py. Journal of Allergy and Clinical by honey bees and wasps. Western
Thus, I am a doctor, a beekeeper, and a Immunology. 105(2 Pt 1):385-390. Journal of Medicine. 170(4):223-227.
patient. In addition to all the photo credits, Golden DBK, Kagey-Sobotka A, Winston ML. 1987. The Biology of the
Id also like to thank two excellent aller- Norman PS, Hamilton RG, and LM Honey Bee. Harvard University Press,
gists for their review of this article: Aneysa Lichtenstein. 2004. Outcomes of aller- Cambridge, MA.