| Abstract [eng] |
Objective. To evaluate the connection between Hymenoptera venom allergy and mast cell disorders, discuss diagnostic and therapeutic strategies, and assess the clinical importance of these conditions through a clinical case and review of the literature. Methods. A clinical case was described and analyzed. Literature searches were conducted in PubMed, Scopus, and Google Scholar using specific keywords and predefined inclusion criteria. The snowballing method was also applied to identify relevant literature. Zotero, a reference management software, was used to organize and cite the selected publications. Clinical Case. In 2023, a 39-year-old patient was referred to an allergist–clinical immunologist due to recurrent systemic reactions following Hymenoptera stings. The patient’s history indicated anaphylactic reactions mainly characterized by weakness, dizziness, loss of consciousness, vomiting, and diarrhea. Allergy testing showed elevated specific immunoglobulin E levels to Hymenoptera venom (bees and wasps). Given recurrent systemic reactions, additional laboratory testing was performed, revealing an elevated baseline serum tryptase level. The patient was referred for further evaluation of a possible mast cell disorder. After a comprehensive hematological examination, including bone marrow examination, and evaluation of clinical and laboratory data, the 4 diagnosis of indolent systemic mastocytosis was confirmed. Since no systemic organ involvement was found, specific hematologic treatment was not started. Due to the higher risk of severe reactions, venom immunotherapy was recommended, and the patient was educated on trigger avoidance and proper use of an epinephrine auto-injector in case of anaphylaxis. In September 2023, the patient started double venom immunotherapy using a cluster schedule. During treatment, wasp venom was well tolerated, but after receiving a 100 µg dose of bee venom, the patient developed anaphylaxis, presenting with flushing, rapid heartbeat, weakness, shortness of breath, and low blood pressure (80/40 mmHg). Emergency treatment with epinephrine, intravenous fluids, oxygen, corticosteroids, and antihistamines stabilized the patient. The venom immunotherapy protocol was adjusted: the dose was temporarily lowered, then gradually increased to 200 µg. Throughout therapy, the patient had multiple stings: bee stings were tolerated, but a possible wasp sting caused another anaphylactic episode, leading to an increase in the wasp venom maintenance dose. Subsequent sting provocation tests with both insects were negative. Conclusions. Hymenoptera venom allergy can cause severe systemic reactions, sometimes without skin symptoms, emphasizing the need to consider an underlying mast cell disorder. Systemic mastocytosis is a significant risk factor for anaphylaxis, leading to a more severe clinical course, a higher likelihood of recurrent reactions, more frequent systemic adverse reactions during immunotherapy, and the need for long-term treatment. In adults, cutaneous mastocytosis is rare, so diagnosing systemic disease often requires a comprehensive evaluation. In clinical practice, additional risk assessment tools, like the Spanish Network on Mastocytosis score, can help identify patients who need further investigation. Allergen-specific immunotherapy is the main treatment for Hymenoptera venom allergy, reducing the risk of systemic reactions and enhancing quality of life. However, therapy in patients with mastocytosis requires careful, individualized assessment. |
