Death Due to Live Bee Acupuncture Apitherapy References

Practitioner's Corner 45

Table. In Vitro Test Resultsa Death due to Live Bee Acupuncture Apitherapy Total IgE 20 KU/L

Vazquez-Revuelta P, Madrigal-Burgaleta R Apis mellifera sIgE 5.99 KUA/L Allergy Division, Ramon y Cajal University Hospital, Madrid, Polistes species <0.35 KUA/L Spain Vespula species <0.35 KUA/L

J Investig Allergol Clin Immunol 2018; Vol. 28(1): 45-46 rApi m 1 0.54 KUA/L doi: 10.18176/jiaci.0202 Basal serum tryptase 8.01 ng/mL

a Key words: Apitherapy. Anaphylaxis. Allergy. Hymenoptera. Death. Specific IgE assays (ImmunoCAP assay, Phadia) Palabras clave: Apiterapia. Anafilaxia. Alergia. Himenópteros. Muerte. an EKG, chest x-ray, and basic blood analyses were normal. Unfortunately, tryptase was not determined during the acute episode. Basal serum tryptase was normal. During admission, in vitro tests were performed 3 days after the reaction, as soon Apitherapy is the use of substances from honeybees as our allergy department was consulted (Table). In vivo tests (eg, honey, propolis, royal jelly, or even venom), to relieve could not be performed because the patient had received various medical conditions. One type of apitherapy is live antihistamine and her clinical situation was problematic. The bee acupuncture, which involves applying the stinging patient died some weeks later of multiorgan failure. Persistent bee directly to the relevant sites according to the specific hypotension during severe anaphylaxis had caused a massive disease. This practice is often performed in private health watershed stroke and permanent coma with multiorgan care centers or by nonmedical practitioners. Although impairment. some benefits of apitherapy have been reported, published To our knowledge, this is the first reported case of death evidence of its effectiveness and safety is limited, scarce, by bee venom apitherapy due to complications of severe and heterogeneous [1,2]. Most hypersensitivity reactions to anaphylaxis in a confirmed sensitized patient who was hymenoptera venoms are due to accidental insect stings. Only previously tolerant. a few cases of allergic reactions after acupuncture have been Previous tolerance to bee stings does not prevent reported, and most are from areas where traditional medicine hypersensitivity reaction; however, repeated exposure favors is widely used, such as Korea [1,2]. a higher risk of sensitization. In sensitized persons, venom compounds can act as Our data enable us to conclude that measures to identify allergens, causing the release of mast-cell mediators and a sensitized patients at risk should be implemented before spectrum of allergic reactions that can range from mild, local each apitherapy sting. Patients should be fully informed of swelling to severe systemic reactions, anaphylactic shock, or the dangers of apitherapy before undergoing it. Apitherapy even death [3]. Furthermore, repeated exposure to the allergen practitioners should be trained in managing severe reactions was found to carry a greater risk of severe allergic reactions and should be able to ensure they perform their techniques in than in the general population [4]. Various adverse reactions a safe environment, with adequate facilities for management have been reported for apitherapy [2,5]. of anaphylaxis and rapid access to an intensive care unit in We report the case of a 55-year-old woman who had been order to prevent suboptimal management, such as delays in attending apitherapy sessions every 4 weeks for 2 years with treatment (the patient waited 30 minutes before receiving good tolerance. She decided to receive apitherapy to improve intramuscular adrenaline). However, these measures may not muscular contractures and stress. She had no clinical record be possible. Therefore, the risks of undergoing apitherapy may of any other diseases (eg, asthma, heart disease), other risk exceed the presumed benefits, leading us to conclude that this factors, previous reactions of any kind with hymenoptera, or practice is both unsafe and unadvisable. atopy. During an apitherapy session, she developed wheezing, dyspnea, and sudden loss of consciousness immediately after Funding a live bee sting. An ambulance was called, although it took 30 The authors declare that no funding was received for the minutes to arrive. The apitherapy clinic personnel administered present study. methylprednisolone. No adrenaline was available. When the ambulance arrived, the patient’s systolic pressure had Conflicts of Interest dropped to 42 mmHg and her heart rate had increased to 110 bpm. Oxygen saturation was not reported. Treatment was The authors declare that they have no conflicts of interest. administered immediately and consisted of a double dose of adrenaline (0.5 mg each), saline infusion, intravenous corticosteroids, and antihistamines. During transfer to our References hospital, the patient’s blood pressure and heart rate stabilized, although her Glasgow Coma Scale score was 6; therefore, she 1. Lim SM, Lee SH. Effectiveness of bee venom acupuncture in was intubated. At admission, a computed tomography scan alleviating post-stroke shoulder pain: a systematic review and was compatible with watershed stroke, while the results of meta-analysis. J Integr Med. 2015;13:241-7.

2. Park JH, Yim BK, Lee J-H, Lee S, Kim TH. Risk Associated with Bee Venom Therapy: A Systematic Review and Meta-Analysis. Dermatitis Caused by Ingestion of Chia Seeds PLoS ONE 2005;10:e0126971. 3. Casale TB, Burks AW. Hymenoptera-Sting Hypersensitivity. N Tomas-Pérez M1, Entrala A1, Bartolomé B2, Caballero ML1, Engl J Med. 2014;370:1432-9. Quirce S1 4. Siracusa A, Folletti I, Gerth van Wijk R, Jeebhay MF, Moscato 1Department of Allergy, Hospital La Paz Institute for Health G, Quirce S, et al. Occupational anaphylaxis - an EAACI task Research (IdiPAZ), Madrid, Spain force consensus statement. Allergy. 2015;70:141-52. 2Roxall España, Bilbao, Spain 5. Park JS, Lee MJ, Chung KH, Ko DK, Chung H. Live bee acupuncture (Bong-Chim) dermatitis: dermatitis due to J Investig Allergol Clin Immunol 2018; Vol. 28(1): 46-47 live bee acupuncture therapy in Korea. Int J Dermatol. doi: 10.18176/jiaci.0203 2013;52:1519-24. Key words: Allergy. Chia seed. Dermatitis. IgE. Salvia hispanica. Palabras clave: Alergia. Semilla de chía. Dermatitis. IgE. Salvia hispanica.

Manuscript received April 25, 2017; accepted for publication September 25, 2017.

Ricardo Madrigal-Burgaleta Salvia hispanica, commonly known as chia, is a species Hospital Universitario Ramon y Cajal of flowering plant in the mint family, Lamiaceae, that is Servicio de Alergia native to Guatemala, Paraguay, Bolivia, Argentina, and Ctra Colmenar Viejo km 9,100 central and southern Mexico. The seeds are a source of fiber, 28034 Madrid, Spain proteins, and w-3 fatty acids. The proteins contained include Email: [email protected] globulins, albumins, prolamins, and glutelins [1]. Chia seeds are increasingly consumed because they are thought to prevent the development of cardiovascular risk factors [2], and their addition to foods such as breakfast cereals, energy bars, yogurt, and bread is increasingly frequent. Allergy to chia seeds has been reported. One patient experienced an anaphylactic reaction after intake [3], and another developed allergic contact dermatitis to Salvia officinalis (Lamiaceae) extract [4]. However, no cases have been published to date in the literature describing other types of allergic reaction due to chia seeds. Our aim was to study a case of IgE-mediated reaction induced by chia seeds with an atypical clinical presentation (ie, eczema and dermatitis). A 46-year-old man with a personal history of persistent allergic rhinitis and sensitization to mites and pollens was referred to our clinic. He complained of eczematous and itchy lesions on his hands that had first appeared several months earlier and coincided with the introduction of chia seeds in his diet (he ate chia with yogurt in his breakfast every day). The lesions disappeared spontaneously when he stopped eating the seeds. The allergology work-up was peformed a few weeks after stopping ingestion. Skin prick tests showed positive results to extracts from cat dander, Dermatophagoides pteronyssinus, and pollens of Platanus hispanica, grass, and Cynodon dactylon. Skin prick testing with chia seed extract (10 mg/mL) was positive (3×4 mm). Total serum IgE was 521 kU/L and specific IgE (ImmunoCAP; kUA/L) was positive to extracts of pollen from plane tree (39.3), oak (3.12), and olive (4.0), as well as to cat dander (0.73), hazelnut (2.98), walnut (1.57), peanut (2.58), white bean (2.47), green bean (3.97) lentil (1), soybean (1.43), wheat (2.09), rye (11.1), maize (2.61), oregano (0.75), sesame (2.67), latex (1.25), and rPru p 3 (5.44). Crushed chia seeds were defatted and extracted to determine the culprit allergens. The extract underwent heating at 100ºC for 5 minutes, reduction with 5% 2-mercaptoethanol