Golden D B, Kagey-Sobotka A, Norman P S, Hamilton R G, Lichtenstein L M
Johns Hopkins Asthma and Allergy Center, Baltimore, MD 21224, USA.
J Allergy Clin Immunol. 2001 May;107(5):897-901. doi: 10.1067/mai.2001.114706.
In our 1976 controlled venom immuno rapy trial, 33% of 182 patients with a history of systemic reactions to insect stings were excluded because of negative venom skin test responses. There have been reports of patients with negative skin test responses who have had severe reactions to subsequent stings.
Our aim is to increase awareness about the patient with a negative skin test response and insect sting allergy and to determine the frequency and significance of negative skin test responses in patients with a history of systemic reactions to insect stings.
We prospectively examined the prevalence of negative venom skin test responses in patients with a history of systemic reactions to stings. In patients who gave informed consent, we analyzed the outcome of retesting and sting challenge.
Of 307 patients with positive histories screened for our sting challenge study, 208 (68%) had positive venom skin test responses (up to 1 microg/mL concentration), and 99 (32%) had negative venom skin test responses. In 36 (36%) of the 99 patients with negative skin test responses, the venom RAST result was a low positive (1-3 ng/mL), or repeat venom skin test responses were positive; another 7 (7%) patients had high venom-specific IgE antibody levels (4-243 ng/mL). Notably, 56 (57%) of 99 patients with positive histories and negative skin test responses had negative RAST results. In patients with positive skin test responses, sting challenges were performed in 141 of 196 patients, with 30 systemic reactions. Sting challenges were performed on 37 of 43 patients with negative skin test responses and positive venom-specific IgE and in 14 of 56 patients with negative skin test responses and negative RAST results. There were 11 patients with negative skin test responses who had systemic reactions to the challenge sting: 2 had negative RAST results, and 9 had positive RAST results at 1 ng/mL. The frequency of systemic reaction was 21% in patients with positive skin test responses and 22% in patients with negative skin test responses (24% in those with positive RAST results and 14% in those with negative RAST results).
Venom skin test responses can be negative in patients who will subsequently experience another systemic sting reaction. Venom skin test responses are negative in many patients with a history of systemic allergic reactions to insect stings and may be associated with positive serologic test responses for venom-specific IgE antibodies (sometimes strongly positive results). Venom skin test responses should be repeated when negative, along with a serologic IgE antivenom test. Better diagnostic skin test reagents are urgently needed.
在我们1976年的对照毒液免疫疗法试验中，182例有昆虫叮咬全身反应病史的患者中有33%因毒液皮肤试验反应阴性而被排除。有报道称皮肤试验反应阴性的患者对随后的叮咬有严重反应。
我们的目的是提高对皮肤试验反应阴性且有昆虫叮咬过敏患者的认识，并确定有昆虫叮咬全身反应病史患者中皮肤试验反应阴性的频率及意义。
我们前瞻性地研究了有叮咬全身反应病史患者中毒液皮肤试验反应阴性的患病率。在获得知情同意的患者中，我们分析了重新检测和叮咬激发试验的结果。
在为我们的叮咬激发试验进行筛查的307例有阳性病史的患者中，208例（68%）毒液皮肤试验反应阳性（浓度高达1微克/毫升），99例（32%）毒液皮肤试验反应阴性。在99例皮肤试验反应阴性的患者中，36例（36%）的毒液RAST结果为低阳性（1 - 3纳克/毫升），或重复毒液皮肤试验反应为阳性；另外7例（7%）患者毒液特异性IgE抗体水平高（4 - 243纳克/毫升）。值得注意的是，99例有阳性病史且皮肤试验反应阴性的患者中有56例（57%）RAST结果为阴性。在皮肤试验反应阳性的患者中，196例中有141例进行了叮咬激发试验，其中30例出现全身反应。在43例皮肤试验反应阴性且毒液特异性IgE阳性的患者中有37例进行了叮咬激发试验，在56例皮肤试验反应阴性且RAST结果为阴性的患者中有14例进行了叮咬激发试验。有11例皮肤试验反应阴性的患者在激发试验叮咬后出现全身反应：2例RAST结果为阴性，9例RAST结果在1纳克/毫升时为阳性。皮肤试验反应阳性的患者全身反应频率为21%，皮肤试验反应阴性的患者全身反应频率为22%（RAST结果阳性的患者中为24%，RAST结果阴性的患者中为14%）。
随后会经历另一次全身叮咬反应的患者毒液皮肤试验反应可能为阴性。许多有昆虫叮咬全身过敏反应病史的患者毒液皮肤试验反应为阴性，且可能与毒液特异性IgE抗体的血清学试验反应阳性（有时为强阳性结果）有关。皮肤试验反应阴性时应重复进行毒液皮肤试验，并进行血清学IgE抗毒液试验。迫切需要更好的诊断性皮肤试验试剂。
