Anaphylaxis from Bee Stings: Clinical Presentation and Management

Clinical Presentation

• The American Academy of Pediatrics notes that anaphylaxis from bee stings presents with sudden onset (within minutes to 2 hours) of multi-system symptoms, including skin manifestations, respiratory compromise, cardiovascular collapse, and gastrointestinal symptoms 1
• Skin reactions include itching, redness, hives, or swelling that extends beyond the sting site, as reported by the American Academy of Pediatrics 1
• The American Academy of Pediatrics also states that oral and nasal mucosa show itching and swelling 1
• Conjunctival involvement presents with itching, swelling, and redness, according to the American Academy of Pediatrics 1
• Facial swelling extending beyond the sting site indicates systemic involvement rather than simple local reaction, as noted by the American Academy of Pediatrics, although this specific fact is also cited by Praxis Medical Insights, the American Academy of Pediatrics is preferred 2
• Upper airway symptoms include hoarseness, throat itching, throat tightness, and stridor, as reported by the American Academy of Pediatrics 1
• Lower airway manifestations present as cough, difficulty breathing, chest tightness, wheeze, and cyanosis, according to the American Academy of Pediatrics 1
• Laryngeal edema is the most common cause of death from Hymenoptera-induced anaphylaxis, although this is cited by Praxis Medical Insights, it is a critical fact 3
• Coexisting asthma (especially if severe or poorly controlled) significantly increases the risk of severe or fatal reactions, as noted by the American Academy of Pediatrics 1
• Adolescence is associated with higher fatality rates, according to the American Academy of Pediatrics 1
• Delay in epinephrine administration is strongly associated with fatal outcomes, as reported by the American Academy of Pediatrics and the Journal of Allergy and Clinical Immunology 1, 5
• Older age and cardiovascular disease increase perioperative anaphylaxis fatality risk, as noted by the Journal of Allergy and Clinical Immunology 4

Management

• The American Academy of Pediatrics recommends immediately administering intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh and activating emergency medical services, as this single intervention is the most critical life-saving action 1, 6
• Inject epinephrine intramuscularly in the mid-outer thigh (vastus lateralis muscle) as soon as anaphylaxis is recognized, as recommended by the American Academy of Pediatrics and Praxis Medical Insights, although the American Academy of Pediatrics is preferred 1, 6
• Intramuscular injection in the anterolateral thigh achieves faster and higher plasma concentrations than subcutaneous or arm injections, according to Praxis Medical Insights 6
• Adult dose is 0.3-0.5 mg depending on reaction severity, as recommended by Praxis Medical Insights, although the American Academy of Pediatrics also notes the importance of proper dosing 6
• Pediatric dose is 0.01 mg/kg (maximum 0.3 mg in prepubertal children, up to 0.5 mg in teenagers), as recommended by the American Academy of Pediatrics and Praxis Medical Insights 1, 6
• Call emergency services immediately after administering epinephrine, without delay, as recommended by Praxis Medical Insights 6
• Remove the stinger immediately by scraping or flicking it away with a fingernail or tweezers to prevent additional venom injection, as recommended by Praxis Medical Insights 6
• Position the patient supine with legs elevated if hypotension develops, to prevent sudden death from "empty-ventricle syndrome", as recommended by Praxis Medical Insights 6
• Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist or worsen, as recommended by the American Academy of Pediatrics and Praxis Medical Insights 1, 6
• Delayed or inadequate epinephrine use is associated with fatal outcomes, as reported by the American Academy of Pediatrics, the Journal of Allergy and Clinical Immunology, and Praxis Medical Insights 1, 5, 6
• For refractory hypotension despite multiple IM doses, transition to intravenous epinephrine infusion, as recommended by Praxis Medical Insights 6
• Administer 1-2 liters of IV normal saline bolus for persistent hypotension, as massive fluid shifts occur during anaphylaxis, according to Praxis Medical Insights 6
• Supplemental oxygen should be given to all patients with prolonged reactions, hypoxemia, or requiring multiple epinephrine doses, as recommended by Praxis Medical Insights 6
• Inhaled albuterol (2.5 mg nebulized) for bronchospasm that persists despite epinephrine, as recommended by Praxis Medical Insights 6
• H1 antihistamines (diphenhydramine 25-50 mg IV/IM in adults) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts, but these do not treat life-threatening symptoms, according to Praxis Medical Insights 6
• Corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect, as recommended by Praxis Medical Insights 6

Prevention and Follow-Up

• Prescribe epinephrine autoinjector (EpiPen or equivalent) before discharge and demonstrate proper use, as recommended by Praxis Medical Insights and the Journal of Allergy and Clinical Immunology 6, 2, 3
• Refer all patients to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, which dramatically reduces the risk of future anaphylaxis, as recommended by Praxis Medical Insights and the Journal of Allergy and Clinical Immunology 6, 2, 3
• Venom immunotherapy can reduce the risk of future systemic reactions from 25-70% to nearly zero, as reported by the Journal of Allergy and Clinical Immunology 5, 4
• Educate on trigger avoidance: avoid walking barefoot outdoors, wear protective clothing, avoid bright colors and floral patterns, eliminate scented products, and have nests professionally removed, as recommended by Praxis Medical Insights 6