Few diseases are as curable as stinging insect allergies, with venom immunotherapy (VIT) offering up to 98 per cent protection from further stings. The problem with VIT is not so much in the treatment as it is in the diagnosis. To provide VIT, a history of a systemic reaction to a stinging insect must be determined, as well as the presence of venom-specific IgE. Although current diagnostic procedures are sensitive and specific, they are not without flaws, and some newer testing alternatives are not generally available. A patient with a credible and convincing history of a systemic allergic response but negative venom-specific tests is a dilemma that occasionally arises. This diagnostic quandary provides a chance to examine probable explanations of this diagnostic difficulty. Venom-specific skin testing has long been the cornerstone of venom sensitivity evaluation, and it is frequently supplemented with in-vitro assays to provide clarity, although even these can fall short on occasion. Investigating innovative venom diagnostic testing procedures may aid in filling some diagnostic gaps. Do existing venom vaccines cover all of the major venom species? Is it possible that there are enough variations across bug species that we are just missing the important allergens? What is the importance of carbohydrate moieties’ antigenicity in venoms? What function do recombinant venom extracts play?

VIT is the only therapy for those who are allergic to insects. Identification of the appropriate Hymenoptera is required before using VIT. Unfortunately, this is not always possible. This deficit can be caused by a variety of factors, including a potential concomitant illness such as occult mast cell disease, limits in currently available diagnostic tools, or testing vaccinations with insufficient coverage of important venom allergens.

Reference: https://journals.lww.com/co-allergy/Abstract/2015/08000/A__difficult__insect_allergy_patient__reliable.14.aspx

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