The following is a summary of “Venom Anaphylaxis: Decision Points for a More Aggressive Workup,” published in the July 2023 issue of Allergy and Clinical Immunology by Bonadonna et al.
Patients presenting for evaluation of insect venom allergy may undergo multiple levels of diagnostic testing. A comprehensive initial medical history is essential for diagnosis and prognosis. The severity of previous sting reactions and the presence or absence of urticaria or hypotension predict the severity of future sting reactions and the presence of underlying mast cell disorders.
Venom skin tests and specific IgE measurements can confirm the diagnosis, but their ability to predict the frequency and severity of future reactions is limited. True allergy can be distinguished from cross-reactivity to honey bees and yellowjacket venoms by testing serum IgE to recombinant venom component antigens. Basophil activation assays can enhance the detection of venom allergy, predict the severity of reactions, and determine the efficacy of venom immunotherapy, but their availability is limited.
An elevated basal serum tryptase level is an important marker for severe anaphylaxis to insect stings and underlying mast cell disorders (such as hereditary -tryptase mia and clonal mast cell disease). When high suspicion exists (e.g., using the Red Espanola de Mastocytosis score), a bone marrow biopsy is the definitive method for characterizing mast cell disorders associated with the most severe outcomes in patients with insect sting allergy.