BEE VENOM ALLERGY

PRESENTED BY: SHAFI MOJADADI

IN THE NAME OF GOD

1) Introduction

2) Taxonomy of the hymenoptra

3) The biology of honey bee

4) Bee venom composition

5) Allergy to bee sting (mechanisms)

6) Factors involved in allergy to bee sting

7) Epidemiology

8) Classification of reactions

9) Diagnosis

10) Treatment

11) Hymenoptra venom immunotherapy(VIT)

12) Recombinant allergens

13) Mechanisms of action of hymenoptra venom immunotherapy

14) apitherapy

Introduction

HYMENOPTRA

Apidae Vespidae Formicidae

TAXONOMY OF HYMENOPTRA

Order

Family

Apis spp.

Bombus spp.

Megabombus spp.

Pyrobombus spp.

Halictus spp.

Dialictus spp.

Vespula spp.

Dolichovespula spp.

Polistes spp.

Solenopsis spp.

Pogonomyrmex spp.

Genus

Bumble Bee

Bombus spp.

Apidae

Vespula spp.

Yellow jacket

Vespidae

 

Vespula vidua  

Vespula spp.

Vespula maculifrons

Vespula consobrina

Vespidae

                              

                             

Dolichovespula arenaria(yellow hornet)

Dolichovespula spp.

Dolichovespula maculata (White-faced hornet)

Vespidae

Paper Wasp

Polistes spp.

Vespidae

Solenopsis invicta

(Fire ant)

Formicidae

Apis mellifera(honey bee)

The bilogy of honey bee(apis mellifera)

Kingdom:animalia

Phylum: arthropoda

Class: insecta

Family: apidae

Genus: apis

Species: apis mellifera

Queen Drone Worker

relativesize

large medium small

#/hive 1 ~200 or 0 20K-200K

lifespan 2 yearsdepending on #sperm

21-32 days spring90 days summeror until mating0 winter

20-40 days summer(worked to death)140 days winter

sex female/bisexual male sterile female

functions -kill sisters and mother-mate with males-lay 1500 eggs/day  = 200K eggs/year-secrete pheromone = 9-hydroxydecenoic acid HOOC=C-C-C-C-C-C-COH-C

-mate with young queen -tend larvae-tend young drones-tend queen-clean hive-gather nectar-gather pollen-gather propolis-evaporate nectar-defend hive-starve drones-lay drone eggs-move larvae formaking new queen

PEPTIDES

melittin (family)melittin Fapamin

mast-cell degranulation peptide 401 (MCD)secarpintertiapinadolapin

protease inhibitorprocamine A, B

miniminecardiopep

ENZYMES

phospholipase A2hyaluronidase

acid phosphomonoesteraseglucosidase

lysophospholipase

 

ACTIVE AMINEShistaminedopamine

norepinephrineleukotriens

 

NON-PEPTIDE COMPONENTS

 carbohydrates like:

GlucoseFructose

 

LIPIDS 6 phospholipids

 

AMINO-ACIDSr-aminobutyric acid

B-aminoisobutyric acid

Bee venom compositionpH 5-5.5

A:liquid

Colorless

sharp-bitter tasting

B:Dried

Yellowish brown

LD50:2.8mg/kg (IV)

(In mice)

Cold resistance

Heat resistance (when dry)

COMPONENT MOL. Wt. % (Dry Venom)

PEPTIDES

Melittin 2,840 40-50

Apamin 2,036 2-3

MCD-Peptide 401 2,588 2-3

Adolapin 11,500 1.0

Protease inhibitor 9,000 < 0.8

Secarpin 0.5

Tertiapin 0.1

Melittin F 0.01

Procamine A, B 1.4

Minimine 6,000 2-3

Cardiopep < 0.7

ENZYMES MOL. Wt. % (Dry Venom)

Hyaluronidase

38,000 1.5-2.0

Phospholipase A2

19,000 10-12

Glucosidase 170,000 0.6

Acid Phosphomono-esterase

55,000 1.0

Lysophospholipase

22,000 1.0

ACTIVE AMINES

Histamine

Dopamine 0.13-1.0

Norepinephrine

0.1-0.7

NON-PEPTIDE

COMPONENTS

Carbohydrates: Glucose & Fructose

< 2.0

Dried bee venom composition

Phospholipase A (enzyme)

•radioprotective activity; •mastocytolitic; •histamine release; •blood pressure depressants •antigenic properties; it is the major BV allergen ; •antagonistic effect on staphylococic alfa-toxin and tetanus toxin; •antitumoural effect •acts on biological membranes

Hyaluronidase

•selectively attacks tissue hyaluronic acid polymers;•increase the capillary permeability (Neumann and Habermann);•immune response and tissue-spread properties;•antigenic;•anaphylactogene

 Apamin (a polypeptide with 18 amino

acids)•antigenic and;•anti-inflammatory properties

Mast Cell Degranulating peptide

In many animal studies, in comparison studies with hydrocortisone, this peptide was 100 times more

potent as an anti-inflammatory agent in suppressing the development of adjuvant-induced arthritis. (Simics

p 13) & quot.

B.V. SUBSTANCES AND THEIR EFFECTS:

Adolapin •analgesic (Shkenderov, 1982);•anti-inflammatory (Shkenderov, 1982)

Melittin (a polypeptide also consisting of 26 amino acids which represents 40-60% of the bee venom)

•antibacterial; •antifungal; •anti-lyme disease (in vitro experiment) •antitumoural; •central nervous system inhibitory; •block nerve muscle and ganglial synapses; •contraction of the striated and smooth muscles; •histamine releasing; •mastocytololysic; •radio protecting (against X-irradiation; study on mice, Shipman and Cole, 1967); •vascular permeability increasing; •haemolysis; •lowers blood pressure; •anti-inflammatory; •mellitin (which represents 40-60 % from the B.V. substances) has no antigenic properties (Orlov); otherwise, according to Artemov, the bee enemies would have gotten a specific immunity; •stimulate the pituitary - adrenal axis to release both cathecolamines and cortisol (Brooks et al.); •increase plasma cortisol levels •acts on biological membranes Presently, it is one of the most potent anti-inflammatory agents known, and it can be useful in treating arthritis and rheumatism.

B.V. SUBSTANCES AND THEIR EFFECTS(continued)

Cardiopep

•increase both the force of contraction (beta-adrenergic) and the heart rate with little or no effect on coronary circulation (Brooks et al.);•anti-arrhythmic properties (Brooks et al.);•stimulate the pituitary - adrenal axis to release both cathecolamines and cortisol (Brooks et al.)

آلرژي به زهر زنبور مرگ در هر سال50-40 آمريکا:

مرگ در هر 1ساليانه استراليا:ميليون نفر

سال3مرگ در هر 1 نيوزيلند:

کمترين ميزان مرگ ومير اسپانيا:مکانيسم باعث بروز آلرژي مي 3زهر زنبور با استفاده از

شود:

Non-igE mediated1)

igE mediated2)

Histamine&leukotriens3)

1) Non-IgE mediated

dried venom, 2.850 kd,26 aa ٪ Melittin: 50

a) effects:histamine releasing,vascular permeability,RBC lysis,low blood pressure

b) Melittin has sequences like CH4 domain of IgE molecule

2) IgE mediated

Major allergens: PLA2, Hyaluronidase,acid phosphatase,melittin

Mast cell,basophil,IgE,IL-4,IL-13

Th0 shift into th2

mediators

Preformed synthesized (histamine)

Newly synthesized(PGD2,LTC4,LTD4.LTE4)&(IL1,4,5,6,13)

3) Histamine&leukotriens

Factors involved in bee venom allrgy

1) PLA2

High dose IL-12

Lowe dose IL-4

Allergen dose IL4/IFNγ

HLA DR4 & HLADQW3(decrease) Bee venom allergy (increase)2) Genetic background:

DRB1*07 allels (allergic individals) (faux et al.)

3) CD40 ligand (T cell),CD40(Bcell) & CD28/CTLA4(T cell),CD86/CD80(APC)

Epidemiology

:مرگ در هر ميليون نفر در هر سال(بيشتر مرگ و 0.45-0.09 ميزان مرگ ومير سال)40مير ها در افراد باالتر از

.ميزان مرگ ومير درکشورهاي اسکانديناوي به مراتب کمتر از قسمتهاي جنوبي اروپا مي باشد

درصد زنبورداران مرد مي 80حساسيت در مردها بيشتر از زنها مي باشد(در کشور فنالندباشند)

در جمعيت انسانيIgE:درصد ب:به زهر زنبورهاي 17-6 اختصاصي الف:به زهر زنبور عسلدرصد21-12غير عسلي:

درصد زنبورداران 79 - 51در سرمIgE.اختصاصي به زهر زنبورهاي عسل وجود دارد

31 درصد از زنبورداران و اعضاي فاميلشان عالوه بر حساسيت به زهر زنبورهاي عسل ،بهترکيبات بدني زنبورها حساسيت نشان مي دهند(عالئم چشمي و بويائي در هنگام کار با کندوي

زنبورهاي عسل).

درصد 43-22درصد و واکنشهاي سيستميک آلرژيک در38-31واکنشهاي موضعي بزرگ درزنبورداران گزارش شده است.

25-32.درصد افرادي که نسبت به نيش حشرات آنافيالکسي دارند،افراد اتوپيک مي باشند

Classification of reactions

reactions

1) Immediate reactions(< 4 hrs)

A:local reaction

B:large local reaction

C:systemic reaction

2) Delayed reactions(>4 hrs) :usually present as progressive swelling and erythema at the sting site but may rarely present as serum sickness-like reactions, Guillain-Barre syndrome, glomerulonephritis

or myocarditis.

Toxic reactions : non immunologic,exogenous vasoactive amines

Bradykinin

Acethylcholin

Dopamine

Histamine

Seretonine

Fatal toxic reactions from Africanized honeybees(AHB) :may be accompanied by intravascular hemolysis, adult respiratory distress syndrome, renal failure, and diffuse intravascular coagulation(DIC)

(Bee venom)

IMMEDIATE REACTIONS

Local reaction symptoms: Transient pain,erythema and swelling at the sting site(2cm diameter).

Larg local reaction symptoms: erythema and swelling(10 cm diameter) for 24 hrs.

Systemic reaction symptoms:

Grade 1: anxiety,malaise,urticaria,pruritus.

Grade 2: abdominal cramping, nausea and/or vomiting.

Grade 3:hoarseness,dysphagia , stridor,wheezing, palpitation, dyspnea,feeling of impeding doom.

Grade4: extensive hypotension, vascular collapse ,death

                                                         

Figure 1. Local reaction to a fire ant sting.

Local reaction to a fire ant sting

Large local reaction to a yellow jacket sting

Systemic reaction

Diagnosis

درصد 10 نمي باشد(IgEواکنشهاي فوري به نيش حشرات هميشه وابسته به قابل دتکت نداشته IgEافرادي که تجربه واکنشهاي آنافيالکتيک داشته اند،هيچ

اند).

Aالف:پيريک تست ب: انترادرمال تستهاي پوستي :

مزيت: سريع،ارزان و حساس

honey bee,yelllow jacket,yellow hornet,white-faced رده هيمنوپترا 5سموم hornet wasp

-yelllow jacket,yellow hornet,whiteترکيبي مساوي از زهر وسپيد شامل: faced hornet

B :تستهاي سرولوژيکي RAST,RIST,ELISA

انواع تستها

افرادي با تست پوستي منفي با سم حشرات گزارش شده اند که بعد از نيش زدگي دچار - 1

.آنافيالکسي گرديده اند

درصد افراد ايمن نشده داراي تست پوستي مثبت ممکن است بعداز نيش زدگي 40حدود - 2 دچار آنافيالکسي نشوند.

:نکات

مي بايست به کراس راکتيويتي بين سموم مختلف توجه کرد! بعنوان مثال بين آنتي ژنها و آلرژنهاي توجه: کراس راکتيويتي وجود vespulaجنس گونه هاي مختلف

)v.germanica,v.vulgaris,v.flovopilosa,v.maculifrons,v.squamousدارد(

polistesهمچنين بين گونه هاي مختلف جنس (p.exclamans,p.apachus,p.instablis,p.annularis,p.fuscatus)

نيز کراس راکتيويتي وجود دارد. solenopsis (s.ivicta s.richteri,)=fire antبين سموم

کراس راکتيويتي وجود دارد.همچنين بين bumble beeبين آنتي ژنهاي موجود درزهر زنبورعسل و vesidهيالورونيداز زنبور عسل و

از طرف ديگر بين آلرژنهاي عمده فاميلهاي مختلف حشرات کراس راکتيويتي وجود ندارد.

.دردسترس مي باشند

Treatment

رعايت نکات زير مي تواند کمک کننده محل نيش را با آب و صابون بشوييد.باشد:

با گذاشتن يک کيسه يخ يا جوش شيرين در محل مي توان جلوياحتياج به درمان خاصي ندارد.رعايت نکات فوق مي واکنشهاي موضعي:دردوتورم بيشتر را گرفت..تواند کمک کننده باشد

با يک کمپرس آب يخ بموقع درمان مي واکنشهاي موضعي بزرگ:شوند.اگر چه ممکن است در چنين مواردي آنتي هيستامينها و

گلوکوکورتيکوئيدها نيز تجويز شوند.

IM وزن بدن mg/kg 0.1 (1000/1اپي نفرين مايع واکنشهاي سيستميک:or IV ميلي ليتر براي 0.5ميلي ليتر براي کودکان و0.3.ماکزيمم

بزرگساالن)

آدرنرژيک(افزايش مقاومت رگي αمکانيسم اثر اپي نفرين : خواص سيستميک و افزايش فشار دياستوليک)

آدرنرژيک(برونکوديالسيون) β خواص

H1همچنين استفاده از آنتي هيستامينهاي بلوک کننده گيرنده (Dyphenhydramine).بعنوان مکمل،براي پايين آوردن خارش و کهير

وآنتي هيستامينها Epipenتوجه: افراد بسيار حساس را مي بايست با .(اين افراد مي بايست ايمونوتراپي شوند).مجهز کرد

Hymenoptra venom immunotherapy(VIT)

VITبا توجه به اين که ايمونوتراپي براي چه کساني توصيه مي شود؟مشکل وپر خرج مي باشد،توصيه مي شود درافرادي که تاريخچه واکنشهاي

اندوتست پوستي آنها مثبت سيستميک(عالئم قلبي وعروقي وتنفسي) داشته درسرمشان قابل دتکت مي باشد، صورت گيرد.IgEمي باشد يا

. نبايد صورت گيردVITنکته: در مورد زنان حامله

VIT درصد موارد حساسيت 95 درصد موارد حساسيت به زنبورعسل و80 در 5 تا کمتر از 60-40نسبت به ديگر زنبورها موثر است.و خطر آنافيالکسي را از

درصد در افرادي که واکنشهاي سيستميک نشان مي دهند،کاهش مي دهد.

History :1911 Freeman&Noon(pollen toxin,hay fever)

1925 Braun (insect sting allrgy)

1940-1956 Benson( prepared a venom extract derived from powdered whole bodies of the insects)

1976-1978 Hunt et al .demonstrated that the constituent proteins in the venoms of these insects where the allergens responsible for the immediate

hypersensitivity reactions to their sting

SELECTION OF THE VENOM

The selection of the venom to be used for immunotherapy is based on the clinical history and on the positive results of the diagnostic tests with the various different venoms.

Difficulties may arise if the tests have been positive to more than one venom.

the greatest problem being to establish whether these positive results represent true allergy to all the venoms or whether they simply indicate cross-reactivity between them.

IMMUNOTHERAPY PROTOCOLS

The therapy protocol is initiated with very low doses, usually 0.01 to 0.1 µg, which are then gradually increased until the maintenance dose is reached.

Cluster schedule: involve a few injections given at each visit, usually at intervals of one week or less.

Rush schedul: can reach the 100-µg maintenance dose within one day, or even within a few hours.

Recombinant allergens

History

1998-1991: The first allergen-encoding DNA sequences were published.

Shortly thereafter, recombinant allergens were produced by expression of allergen-encoding cDNAs mainly in prokaryotic (Escherichia coli) expression systems and then tested for their IgE-binding capacity and for their ability to induce specific activation of T cells and basophils .

1994–1995: the first recombinant allergens were successfully used for in -vivo diagnosis of Type I allergy in patients by skin testing.1996:The first three-dimensional (3D) allergen structures solved by X-ray crystallography and NMR were published.Then the first recombinant allergen variants with reduced allergenic activity were reported and suggested as hypoallergenic candidate molecules for safer forms allergen-specific immunotherapy.

Mechanisms of action of hymenoptra venom immunotherapy

VIT

IgE IgG4

Th2 shift into th1

Increase IL-10 production (IL-10 blocks CD28-dependent costimulatory signaling pathways in T cells. IL-10 initiates peripheral T-cell anergy by blocking tyrosine phosphorylation of CD28 and subsequently the CD28 costimulatory signal.

ApitherapyMelittin: the most prevalent substance, is one of the most potent anti-inflammatory agents known (100 times more potent than hydrocortisol). Melittin also stabilizes the lysosome cell membrane to protect against inflammation.

Apamin: inhibits complement C3 activity, and blocks calcium-dependent potassium channels, thus enhancing nerve transmission.

Melittin and Apamin: found in bee venom have been shown to stimulate the pituitary gland in humans and animals, releasing a hormone that causes the adrenal gland to produce cortisol, one of the body's major anti-inflammatory agents!

Adolapin: is another strong anti-inflammatory substance, and inhibits cyclooxygenase; it thus has analgesic activity as well.

Peptide 401( MDC peptide): blocks the arachidonic acid and inhibits prostaglandin synthesis.

Protease inhibitors: inhibit carrageenin, prostaglandin E1, bradykinin, and histamine induced inflammations .

ALLERGIES (ALLERGOLOGY)

BV Allergy Bee Pollen AllergyHay feverRagweed polinosis

CARDIOVASCULAR DISEASES (CARDIOLOGY)

Acute rheumatic carditis Angina pectorisArrhythmiasArtheritis obliteransArtheriosclerosisAtherosclerosisAtherosclerotic Arteritis of the Inferior Limbs etc.Capillary fragilityCardiac diseases (non-specific)Cerebral atherosclerosisCerebral TrombosisCoronary Heart DiseasesFlebitisHeart insufficiencesHaemorrhagies of vascular originHigh Blood PressureLiver congestionPeripheral Ischemic Degenerative SyndromePeripheral Vascular DiseasesRaynaud’s DiseaseSlow peripheral blood flowVaricose ulcerVaricosis

Diseases and Apitherapy There are over 500 diseases and/or conditions which may be prevented or treated through the use of apitherapy.

Blood diseases (HEMATOLOGY)

Anaemia Coagulation diseases with aplasiaHaemorrhagic gingivitisHyperlipidaemia

Respiratory apparatus diseases (PNEUMOLOGY)

Allergic rhinitis (hay fever) AnginaAsthmatic bronchitisBronchial asthmaBronchiectasisBronchitisChronically coughChronic non-specific diseases of lungsCoughInflammatory diseases of the upper respiratory tractInfluenza infectionLaryngitisNon-specific chronic pneumoniaNon-specific endo-bronchitisNon-specific pneumoniaPulmonary tuberculosisRhinitisTracheitisTuberculosis

Diseases and Apitherapy

CANCERS (ONCOLOGY)

Basal cell carcinoma Chemotherapy (during)Gynaecologic cancer (non-specific)LymphomaMalignant melanomaMammary tumours

MUSCULOSKELETAL SYSTEM DISEASES (RHEUMATOLOGY, MYOLOGY, OSTEOLOGY)

Acute and Chronic Bursitis Ankylotic SpondyilarthritisAnkylotic Spondylitis DeformansArthritisArthrosisFibrositisJuvenile ArthritisLateral Epicondylitis (Tenis Elbow)Muscle Tonus Problems Ligament TroublesMyalgiaOsteoarthritisPeriarthritis of the shoulder with calcificationsPoliarthritis DeformansPsoriatic ArthritisReduced Muscle Force (Weak Muscles = Hypotonia)Rheumatic afflictions of muscles, nerves and articulations, etc.Rheumatic diseases (non-specific) Rheumatoid arthritisScheuermann’s Disease (osteochondrosis)Spondyloarthrosis (Clinical Arthrosis)Traumatic Arthritis

The exuded sting with a small drop of venum on it

The sting and its poison gland attached

Closeup of the sting showing the barbs, which allows the sting to anchor inside the victim's flesh, much like the barb on a fishing hook.

A worker bee trying to get away after stinging. The sting has barbs preventing the sting to be pulled out, part of her digestive system is seen dragging behind her

Two minutes after being stung. The sting is removed to show the site of sting entry

The site of a sting injury after 24 hours. Light red and swelling is seen, a small scar tissue is forming at the site of sting entry.

Urticaria (hives) on a person, who is having a systematic reaction to a bee sting. This can be a prelude to an anaphylactic response, which can be fatal if not treated immediately.

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