Ruëff F, Wenderoth A, Przybilla B
Clinic and Policlinic for Dermatology and Allergology, University of Munich, Munich, Germany.
J Allergy Clin Immunol. 2001 Dec;108(6):1027-32. doi: 10.1067/mai.2001.119154.
Up to 20% of patients allergic to Hymenoptera venom are not protected by conventional venom immunotherapy (VIT) with 100 microg of any single venom.
We sought to evaluate the efficacy of an increased venom dose in patients allergic to Hymenoptera venom still reacting systemically to a sting challenge despite immunotherapy with 100 microg of venom every 4 weeks.
In this retrospective study patients were included who still had reacted systemically to a sting challenge with a living bee or wasp despite VIT with a maintenance dose of 100 microg every 4 weeks. The maintenance dose was increased to 150 or 200 microg every 4 weeks, and a second sting challenge was performed. If a patient reacted again, the dose was further increased. Baseline mast-cell tryptase levels were assessed by using a fluoroenzyme immunoassay in stored patient sera.
While receiving a maintenance dose of 100 microg of venom every 4 weeks for 7 to 38 months, 18 patients reacted systemically to a bee sting and 22 reacted to a wasp sting. After an increase of the maintenance dose to 150 microg, 2 of 4 patients allergic to bee venom (BV) and 6 of 6 patients allergic to yellow jacket venom (YJV) no longer reacted systemically to the sting challenge. The respective rates of full protection were 13 of 14 and 15 of 16 in patients with an increase of the maintenance dose to 200 microg from the start. Of those 4 individuals not protected by the first dose increase, one patient allergic to BV (prior dose of 150 microg) and one patient allergic to YJV (prior dose of 200 microg) did not react systemically to a further sting challenge while receiving 200 microg of BV or 250 microg of YJV, respectively. One patient allergic to BV who had a systemic reaction to the sting challenge while receiving 150 microg was not protected after a dose increase to 200 microg; she later received a dose of 400 microg of BV, and no further sting challenge was performed. The patient allergic to BV who still reacted systemically after a first dose increase to 200 microg was a female patient with urticaria pigmentosa. She had repeated systemic adverse reactions to further BV immunotherapy, necessitating discontinuation of the treatment; however, she tolerated well VIT with 200 microg of YJV. In all other patients, no unusual adverse reactions to the increased venom doses were observed. Baseline serum tryptase levels were elevated above 13.5 microg/L (95th percentile in normal subjects) in 9 (28.1%) of 32 patients.
The majority of patients allergic to Hymenoptera venom who still reacted systemically to a sting challenge despite VIT with a dose of 100 microg every 4 weeks can be fully protected by an increased maintenance dose. This dose increase is well tolerated by most patients. The rather high proportion of patients with elevated baseline serum tryptase levels necessitates further investigation of a possible association between mastocytosis and treatment failure of conventionally dosed VIT.
高达20%对膜翅目昆虫毒液过敏的患者未受到常规毒液免疫疗法（VIT）的保护，这种疗法使用任何单一毒液100微克。
我们试图评估增加毒液剂量对尽管每4周接受100微克毒液免疫疗法但对蜇刺激发试验仍有全身反应的膜翅目昆虫毒液过敏患者的疗效。
在这项回顾性研究中，纳入了尽管每4周接受100微克维持剂量的VIT但对活蜜蜂或黄蜂蜇刺激发试验仍有全身反应的患者。维持剂量增加至每4周150或200微克，并进行第二次蜇刺激发试验。如果患者再次出现反应，剂量进一步增加。使用荧光酶免疫测定法在储存的患者血清中评估基线肥大细胞类胰蛋白酶水平。
在每4周接受100微克毒液维持剂量7至38个月期间，18例患者对蜜蜂蜇刺有全身反应，22例患者对黄蜂蜇刺有全身反应。将维持剂量增加至150微克后，4例对蜂毒（BV）过敏的患者中有2例以及6例对黄夹克毒液（YJV）过敏的患者中均无患者对蜇刺激发试验再有全身反应。从开始就将维持剂量增加至200微克的患者中，完全得到保护的比例分别为14例中的13例和16例中的15例。在那些未因首次剂量增加而得到保护的4例患者中，1例对BV过敏的患者（先前剂量为150微克）和1例对YJV过敏的患者（先前剂量为200微克）在分别接受200微克BV或250微克YJV时，对进一步的蜇刺激发试验无全身反应。1例对BV过敏且在接受150微克时对蜇刺激发试验有全身反应的患者在剂量增加至200微克后未得到保护；她后来接受了400微克BV的剂量，未再进行蜇刺激发试验。1例对BV过敏且在首次剂量增加至200微克后仍有全身反应的患者是一名患有色素性荨麻疹的女性患者。她对进一步的BV免疫疗法反复出现全身不良反应，不得不停止治疗；然而，她对200微克YJV的VIT耐受良好。在所有其他患者中，未观察到对增加的毒液剂量有异常不良反应。32例患者中有9例（28.1%）基线血清类胰蛋白酶水平高于13.5微克/升（正常受试者的第95百分位数）。
大多数对膜翅目昆虫毒液过敏且尽管每4周接受100微克剂量的VIT但对蜇刺激发试验仍有全身反应的患者可通过增加维持剂量而得到完全保护。大多数患者对这种剂量增加耐受良好。基线血清类胰蛋白酶水平升高的患者比例相当高，这需要进一步研究肥大细胞增多症与常规剂量VIT治疗失败之间可能存在的关联。
