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Selection of patients for venom immunotherapy

Selection of patients for venom immunotherapy
Reaction to sting Result of skin test or venom-specific IgE test Venom immunotherapy indicated?
Non-life-threatening, widespread, cutaneous reaction: Generalized urticaria, angioedema, erythema, pruritus Positive No*
Systemic, life-threatening reaction: Possible cutaneous symptoms but also respiratory symptoms (laryngeal edema or bronchospasm) or cardiovascular symptoms (hypotension, shock) Positive Yes
Systemic reaction Negative NoΔ
Large local reaction (>4 inches or 10 cm in diameter, >24-hour duration) Positive or negative No*
Normal reaction (≤4 inches or 10 cm in diameter, <24-hour duration) Positive or negative No
IgE: immunoglobulin E.
* Exceptions occasionally made.
¶ It is unknown whether this applies to imported fire ant hypersensitivity.
​Δ Patients with a convincing history of a systemic sting reaction but negative tests for venom-specific IgE may be at risk for a future systemic reaction due to unclear mechanisms. This diagnostic dilemma is discussed in the UpToDate topic on diagnosis of Hymenoptera venom allergy.
Original figure modified for this publication. Graft DF. Insect sting allergy. Med Clin N Am 2006; 90:211. Illustration used with the permission of Elsevier Inc. All rights reserved.
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