Two weeks ago my 3 year old Luke, weighing 30 lbs, walked past a fallen hive and was attacked by a swarm of angry bees. He sustained 31 bee stings, 27 on the legs, and others on the head, back, armpit and ear. He experienced no signs of anaphylactic shock, but was miserable from a flaming sensation in the skin for a full day, followed by a week of intense itching. Luke received Benadryl by mouth for the first few days to help the itching, but no other drugs were used. Initially the stings flared up as red bumps, but quickly disappeared within a few hours. Exactly one week later, they reappeared as itchy chicken-pox style bumps, and itched for another week. Today, three weeks later, he has stopped itching, and the red dots are healing. Is there anything else we should be aware of in Luke’s management of future bee stings after this severe exposure? Is there a way to test him in advance for any hypersensitivity he may have developed?
Gale Wilson – MedSeek
Dr. Greeneès Answer:
It’s good to hear from you, Gale, but I’m sorry to hear about Luke’s misadventure! Thirty one stings! I can almost imagine the series of expressions on his face during the onslaught. He must have been terrified. I’m glad Luke has recovered from this as well as he has.
Of the more than one million species of insects on our planet, bees and their close relatives (wasps, yellow jackets, yellow hornets, white-faced hornets, and fire ants) pose the greatest danger to humans. Ironically, they are also perhaps the most beneficial to humans of all insect groups. Dealing with bee stings is relatively simple — unless the child develops an allergy or is stung by many bees.
Bee venom contains at least nine different components that work together to cause reactions in those stung. When a bee injects its venom under the skin, the child may have immediate reactions (those symptoms beginning within 4 hours), delayed reactions (symptoms that don’t appear until more than four hours after the sting), or both (as in Luke’s case). Classifying the reactions is important both for immediate management and for predicting future problems (Allergy Principles and Practice, Mosby 2003).
Some immediate reactions are classified as local (a two – or three-inch area of swelling, redness and pain that lasts less than 24 hours). Others qualify as large local reactions (those that are larger — often an entire limb — or that last longer, but all symptoms are adjacent to stings). Systemic reactions are allergic responses distant from the sting and include symptoms such as hives, generalized itching, generalized swelling, low blood pressure, difficulty breathing, or anaphylactic shock — a severe reaction involving most or all of these symptoms.
A sting on the forehead with swelling of the eyelids is a large local reaction, while a sting on the foot with swelling of the eyelids is a systemic reaction. Large local reactions are rarely serious and rarely portend future severe allergies. Systemic allergic reactions, though, are present and future warning signs.
A fourth type of immediate reaction is the toxic reaction which can follow multiple stings. This is a direct result of bee venom, and not an allergic reaction. Symptoms can include fever, weakness, nausea, vomiting, and pain. It sounds like Luke’s flaming sensation was probably a toxic reaction from his many stings. Toxic reactions are rarely serious, but do sometimes sensitize the child and herald future allergic reactions.
Delayed reactions result when the body’s immune system prepares for future stings, but some of the exuberant defense measures inadvertently turn against the body itself. These symptoms begin more than four hours after the initial sting. Delayed reactions include serum sickness (fever, weakness, rash, swelling, and/or intense itching which begin a week after the sting), nephrotic syndrome (inflammation of the kidney), neuritis (inflammation of the nerves), or inflammation of other parts of the body. It sounds like Luke’s second round of itchy bumps was a serum-sickness like reaction.
Predicting Allergic Reactions
Two types of tests can help predict whether someone will have an allergic reaction to future bee stings. Neither test is perfect, but each can be useful as a supplement to the other. Skin testing is clearly positive in the majority of patients with a convincing history. On the other hand, up to 46% of nonallergic individuals have positive skin tests (Journal of Allergy and Clinical Immunology, 76:803, 1985). Patients with a history of bee-sting related anaphylaxis and a negative skin test should have blood testing as described below and a repeat skin test in 3-6 months (Allergy Principles and Practice, Mosby 2003). Skin testing must be done carefully to prevent systemic reactions in extremely sensitive individuals. It is important to be aware that the degree of positivity of a skin test does not reliably correlate with the severity of the allergic reaction.
A blood test called the RAST test has only about 20% false-negative and false-positive results. Like with skin testing, the level of positivity of the test gives no information about the degree of allergy present.
Neither form of testing is indicated following local or large local reactions alone.
Bee Sting Treatment
Treatment of allergies includes preventing stings, carrying epinephrine (that should be injected following a sting whenever there are any systemic symptoms such as dizziness, swelling of the lips or tongue, or difficulty breathing), corticosteroids, antihistamines, and/or possibly allergy shots. Allergy shots can often desensitize people to bee stings. They are usually reserved for those who have had both a systemic allergic reaction and either positive skin or positive RAST tests. (If the tests were both negative, one wouldn’t know which type of bee allergy shots to give).
Even without treatment, most children outgrow their allergies to bee stings. In one study of 174 untreated children aged 3 to 16 with previous systemic allergic reactions following stings, there were 196 stings over a subsequent four-year period. Only 18 (9.2%) of these subsequent stings produced systemic symptoms — none more severe than the original episode. Symptoms of anaphylactic shock are the greatest predictor of future severe reactions New England Journal of Medicine, 323:1601, 1990.
More than one million people in the United States are allergic to bee stings. Thankfully, only about 40 deaths occur in the U.S. each year — mostly adults. Although I would recommend, Gale, that you consult an allergist, Luke has a great chance of outgrowing (without treatment) any allergy he may have developed from this unpleasant incident (yeeouch!). Take care, and keep up the great work at MedSeek!
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