BEE VENOM ALLERGY

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IN THE NAME OF GOD
BEE VENOM ALLERGY
BEE VENOM ALLERGY
PRESENTED BY SHAFI MOJADADI
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• Introduction
• Taxonomy of the hymenoptra
• The biology of honey bee
• Bee venom composition
• Allergy to bee sting (mechanisms)
• Factors involved in allergy to bee sting
• Epidemiology
• Classification of reactions
• Diagnosis
• Treatment
• Hymenoptra venom immunotherapy(VIT)
• Recombinant allergens
• Mechanisms of action of hymenoptra venom
  immunotherapy
• apitherapy

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Introduction
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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
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Apidae
Bombus spp.
Bumble Bee
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Vespidae
Vespula spp.
Yellow jacket
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Vespidae
Vespula spp.
 
Vespula maculifrons
Vespula vidua  
Vespula consobrina

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Vespidae
Dolichovespula spp.
                             
Dolichovespula arenaria (yellow hornet)
                              

Dolichovespula maculata (White-faced hornet)
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Vespidae
Polistes spp.
Paper Wasp
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Formicidae
Solenopsis invicta (Fire ant)
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The bilogy of honey bee(apis mellifera)
Kingdomanimalia Phylum arthropoda Class
insecta Family apidae Genus apis Species apis
mellifera
Apis mellifera(honey bee)
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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 HOOCC-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
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Bee venom composition
pH 5-5.5 Aliquid Colorless sharp-bitter
tasting BDried Yellowish brown LD502.8mg/kg
(IV) (In mice) Cold resistance Heat resistance
(when dry)
PEPTIDES melittin (family)melittin Fapaminmast-cell degranulation peptide 401 (MCD)secarpintertiapinadolapinprotease inhibitorprocamine A, Bminiminecardiopep
ENZYMES phospholipase A2hyaluronidaseacid phosphomonoesteraseglucosidaselysophospholipase
  ACTIVE AMINES histaminedopaminenorepinephrineleukotriens
  NON-PEPTIDE COMPONENTS   carbohydrates likeGlucoseFructose
  LIPIDS 6 phospholipids
  AMINO-ACIDS r-aminobutyric acidB-aminoisobutyric acid
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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 lt 2.0
Dried bee venom composition
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 lt 0.8
Secarpin 0.5
Tertiapin 0.1
Melittin F 0.01
Procamine A, B 1.4
Minimine 6,000 2-3
Cardiopep lt 0.7
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B.V. SUBSTANCES AND THEIR EFFECTS
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.
Adolapin analgesic (Shkenderov, 1982) anti-inflammatory (Shkenderov, 1982)
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B.V. SUBSTANCES AND THEIR EFFECTS(continued)
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.
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.)
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?????? 40-50??? ?? ?? ??? ???????? ???????1???
?? ?? ?????? ??? ???????? 1??? ?? ??
3??? ??????? ?????? ????? ??? ????
Non-igE mediated1)
??? ????? ?? ??????? ?? 3??????? ???? ???? ?????
?? ???
igE mediated2)
Histamineleukotriens3)
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1) Non-IgE mediated
dried venom, 2.850 kd,26 aa Melittin 50
a) effectshistamine 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,I
L-13 Th0 shift into th2
Preformed synthesized (histamine)
mediators
Newly synthesized(PGD2,LTC4,LTD4.LTE4)(IL1,4,5,6,
13)
3) Histamineleukotriens
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Factors involved in bee venom allrgy
High dose
IL-12
Allergen dose
1) PLA2
IL4/IFN?
Lowe dose
IL-4
HLA DR4
HLADQW3(decrease)
Bee venom allergy (increase)
2) Genetic background
DRB107 allels (allergic individals) (faux et al.)
3) CD40 ligand (T cell),CD40(Bcell)
CD28/CTLA4(T cell),CD86/CD80(APC)
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Epidemiology

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  ?? ???(????? ??? ? ??? ?? ?? ????? ?????? ?? 40
  ???)
• ????? ??? ???? ????????? ??????????? ?? ?????
  ???? ?? ??????? ????? ????? ?? ????.
• ?????? ?? ????? ????? ?? ???? ?? ????(?? ????
  ?????? 80???? ?????????? ??? ?? ?????)
• ?? ????? ?????? IgE ??????? ????? ??? ?????
  ???6-17???? ??? ??? ???????? ??? ????12-21????
• ?? ???51 - 79???? ?????????? IgE??????? ?? ???
  ???????? ??? ???? ????.
• 31???? ?? ?????????? ? ????? ???????? ????? ??
  ?????? ?? ??? ???????? ??? ??? ??????? ????
  ??????? ?????? ???? ?? ????(????? ???? ? ??????
  ?? ????? ??? ?? ????? ???????? ???).
• ???????? ????? ???? ?? 31-38???? ? ????????
  ??????? ?????? ??22-43???? ?????????? ????? ???
  ???.
• 25-32 ???? ?????? ?? ???? ?? ??? ????? ??????????
  ??????????? ?????? ?? ?????.

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Classification of reactions
Alocal reaction Blarge local reaction Csystemic
reaction
1) Immediate reactions(lt 4 hrs)
reactions
2) Delayed reactions(gt4 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.
Bradykinin Acethylcholin Dopamine Histamine Sereto
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Toxic reactions non immunologic,exogenous
vasoactive amines
(Bee venom)
Fatal toxic reactions from Africanized
honeybees(AHB) may be accompanied by
intravascular hemolysis, adult respiratory
distress syndrome, renal failure, and diffuse
intravascular coagulation(DIC)
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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. Grad
e 2 abdominal cramping, nausea and/or vomiting.
Grade 3hoarseness,dysphagia ,
stridor,wheezing, palpitation, dyspnea,feeling
of impeding doom. Grade4 extensive hypotension,
vascular collapse ,death
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Figure 1. Local reaction to a fire ant sting.
Local reaction to a fire ant sting
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Large local reaction to a yellow jacket sting
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Systemic reaction
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Diagnosis
???????? ???? ?? ??? ????? ????? ?????? ?? IgE
??? ????(10 ???? ?????? ?? ????? ????????
??????????? ????? ??????? IgE ???? ???? ??????
???). A ?????? ????? ???????? ??? ?
?????????? ???? ?????????? ? ???? ???? 5 ???
????????? honey bee,yelllow jacket,yellow
hornet,white-faced hornet wasp
?????? ????? ?? ??? ????? ????
yelllow jacket,yellow hornet,white-faced hornet
B ?????? ????????? RAST,RIST,ELISA
????? ?????
??????? ?? ?????.
???? ?? ????? ?? ???? ????????? ??? ???? ?????
???? ???! ?????? ???? ??? ???? ???? ? ????????
???? ??? ????? ??? vespula ???? ????????? ????
????(v.germanica,v.vulgaris,v.flovopilosa,v.maculi
frons,v.squamous) ?????? ??? ???? ??? ????? ???
polistes (p.exclamans,p.apachus,p.instablis,p.annu
laris,p.fuscatus) ??? ???? solenopsis (s.ivicta
s.richteri,)fire ant ??? ???? ????????? ????
????. ??? ???? ????? ????? ????? ???????? ?bumble
bee ???? ????????? ???? ????.?????? ???
???????????? ????? ??? ?vesid ?? ??? ???? ???
???????? ???? ???????? ????? ????? ???? ?????????
???? ?????.
1- ?????? ?? ??? ????? ???? ?? ?? ?????
????? ??? ??? ?? ??? ?? ??? ???? ???? ??????????
?????? ???. 2- ???? 40 ???? ????? ????
???? ????? ??? ????? ???? ???? ??? ????? ??? ????
???? ?????????? ?????.
????
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Treatment
????? ???? ??? ?? ????? ??? ????? ????

• ??? ??? ?? ?? ?? ? ????? ??????.
• ?? ?????? ?? ???? ?? ?? ??? ????? ?? ??? ?? ????
  ???? ???????? ????? ?? ????.

???????? ????? ?????? ?? ????? ???? ?????.?????
???? ??? ?? ????? ??? ????? ????. ???????? ?????
???? ?? ?? ????? ?? ?? ????? ????? ?? ????.???
?? ???? ??? ?? ???? ?????? ???? ?????????? ?
????????????????? ??? ????? ????. ????????
??????? ??? ????? ???? 1000/1 (0.1 mg/kg ??? ???
IM or IV.??????? 0.3???? ???? ???? ?????? ?0.5
???? ???? ???? ?????????) ??????? ??? ??? ?????
???? a ????????(?????? ?????? ??? ??????? ?
?????? ???? ?????????)
???? ß ????????(??????????????) ?????? ???????
?? ???? ??????????? ???? ????? ?????? H1
(Dyphenhydramine) ?????? ????????? ????? ?????
???? ? ????. ???? ????? ????? ???? ?? ?? ?????
?? Epipen ????? ?????????? ???? ???.(??? ????? ??
????? ??????????? ????).
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Hymenoptra venom immunotherapy(VIT)
VIT ???? ?? ????? ????? ?? ???? ?? ???? ?? ??? ??
??????????? ???? ??? ??? ?? ?????????? ?? ???
???????? ?? ??????? ???????? ???????(????? ????
?????? ??????) ????? ??????? ????? ???? ???? ??
???? ?? IgE ???????? ???? ???? ?? ????? ????
????. ???? ?? ???? ???? ????? VIT ????? ????
????. VIT ?? 80 ???? ????? ?????? ?? ????????
?95???? ????? ?????? ???? ?? ???? ??????? ????
???.? ??? ?????????? ?? ?? 40-60 ?? ???? ?? 5
???? ?? ?????? ?? ???????? ??????? ???? ??
????????? ?? ???. History 1911
FreemanNoon(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


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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.

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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 . 19941995 the first
recombinant allergens were successfully used for
in -vivo diagnosis of Type I allergy in patients
by skin testing. 1996The 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.
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Mechanisms of action of hymenoptra venom
immunotherapy
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.
VIT
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Apitherapy

• Melittin 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, prostagl
  andin E1, bradykinin, and histamine induced
  inflammations .

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Diseases and Apitherapy
There are over 500 diseases and/or conditions
which may be prevented or treated through the use
of apitherapy.
ALLERGIES (ALLERGOLOGY) BV Allergy Bee Pollen Allergy Hay fever Ragweed polinosis
CARDIOVASCULAR DISEASES (CARDIOLOGY) Acute rheumatic carditis Angina pectoris Arrhythmias Artheritis obliterans Artheriosclerosis Atherosclerosis Atherosclerotic Arteritis of the Inferior Limbs etc. Capillary fragility Cardiac diseases (non-specific) Cerebral atherosclerosis Cerebral Trombosis Coronary Heart Diseases Flebitis Heart insufficiences Haemorrhagies of vascular origin High Blood Pressure Liver congestion Peripheral Ischemic Degenerative Syndrome Peripheral Vascular Diseases Raynauds Disease Slow peripheral blood flow Varicose ulcer Varicosis
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Diseases and Apitherapy
Blood diseases (HEMATOLOGY) Anaemia Coagulation diseases with aplasia Haemorrhagic gingivitis Hyperlipidaemia
Respiratory apparatus diseases (PNEUMOLOGY) Allergic rhinitis (hay fever) Angina Asthmatic bronchitis Bronchial asthma Bronchiectasis Bronchitis Chronically cough Chronic non-specific diseases of lungs Cough Inflammatory diseases of the upper respiratory tract Influenza infection Laryngitis Non-specific chronic pneumonia Non-specific endo-bronchitis Non-specific pneumonia Pulmonary tuberculosis Rhinitis Tracheitis Tuberculosis
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CANCERS (ONCOLOGY) Basal cell carcinoma Chemotherapy (during) Gynaecologic cancer (non-specific) Lymphoma Malignant melanoma Mammary tumours
MUSCULOSKELETAL SYSTEM DISEASES (RHEUMATOLOGY, MYOLOGY, OSTEOLOGY) Acute and Chronic Bursitis Ankylotic Spondyilarthritis Ankylotic Spondylitis Deformans Arthritis Arthrosis Fibrositis Juvenile Arthritis Lateral Epicondylitis (Tenis Elbow) Muscle Tonus Problems Ligament Troubles Myalgia Osteoarthritis Periarthritis of the shoulder with calcifications Poliarthritis Deformans Psoriatic Arthritis Reduced Muscle Force (Weak Muscles Hypotonia) Rheumatic afflictions of muscles, nerves and articulations, etc. Rheumatic diseases (non-specific) Rheumatoid arthritis Scheuermanns Disease (osteochondrosis) Spondyloarthrosis (Clinical Arthrosis) Traumatic Arthritis
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The exuded sting with a small drop of venum on it
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The sting and its poison gland attached
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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.
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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
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Two minutes after being stung. The sting is
removed to show the site of sting entry
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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.
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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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