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Stinging insect reactions: when to refer.

ESTES PARK, COLO. -- Recognizing which patients with even a breathtakingly dramatic reaction to a hymenoptera sting can be appropriately done by the primary care physician.

Knowing which patients need a referral to an allergy specialist is the key to avoiding a potential lawsuit that's essentially indefensible, according to Dr. Mark A. Ebadi.

A patient needs referral for allergy testing and desensitization therapy only if the swelling or hives occurred in a discontinuous pattern from the site of the sting or if there was anaphylaxis.

Otherwise the patient is best managed in his or her medical home by a primary care physician using reassurance, a short course of oral prednisone, and, if infection is present, a beta-lactam antibiotic, Dr. Ebadi said at a conference on internal medicine sponsored by the University of Colorado.

"I see a patient with an incredibly swollen hand, neck, or leg due to a hymenoptera sting every day during the summer. I tell patients that if you're stung on the hand, even if it swells all the way up your arm and into your neck, that's still a local reaction. That does not portend an anaphylactic reaction the next time you get stung. You're supposed to react to a hymenoptera sting; it's not a big deal," explained Dr. Ebadi of the Colorado Allergy and Asthma Center, Denver.

On the other hand, a patient who got stung on the foot and minutes later experienced facial swelling in a discontinuous pattern, perhaps accompanied by widespread hives and difficulty breathing, has had a systemic reaction with production of IgE in response to hymenoptera of some kind.

"The standard of care in internal medicine for hymenoptera anaphylaxis is referral to a specialist for testing and allergen desensitization. You don't have a leg to stand on if you just give the patient an epi pen and tell them to keep it with them at all times, and then they get stung when they forgot to carry it and they get laryngeal angioedema, airway compromise, and die," he said.

"I see cases like that probably twice a year when attorneys consult with me. I'll review the chart and tell the attorney, 'You should probably settle,'" the allergist added.

For the results of RAST (radioallergosorbent testing) to be meaningful, the testing should be delayed until 1 month after the sting.

It's an excellent idea to give the patient an epi pen and instructions to carry it at all times while waiting for the specialist appointment, said Dr. Ebadi.

He reported having no financial conflicts of interest.

Caption: Refer if there is anaphylaxis, or swelling in a discontinuous pattern.

bjancin@frontlinemedcom.com

BY BRUCE JANCIN

EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM

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Title Annotation:DERMATOLOGY
Author:Jancin, Bruce
Publication:Family Practice News
Geographic Code:1USA
Date:Sep 1, 2013
Words:448
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