The death of naturalist Manuel Mongini after a sting brings attention to a rare but real risk: anaphylactic shock. How to recognize it, why it can be devastating and how to protect yourself.
A sudden pain in the ear, returning home, a soothing ointment and then, within a few minutes, the loss of consciousness. It is the dramatic sequence of the death of Manuel Mongini74 years old, naturalist and ornithologist from the Novara area, stung by a hornet a few days ago while picking vegetables in the garden of his home in Soriso. The man lost consciousness about five minutes after the puncture, before it was possible to provide him with help. To make the story even more tragic there is a coincidence: years earlier his dog had also died following a hornet sting. Mongini’s story does not mean that a hornet sting is normally lethal. On the contrary, in most cases it causes localized pain, redness and swellingdestined to reduce spontaneously. The problem is that, in a minority of people, the poison can trigger a systemic allergic reactionanaphylaxis, capable of rapidly evolving to compromise of the respiratory tract, a sharp drop in blood pressure, loss of consciousness and cardiac arrest. It is a true medical emergency and you should not wait for the symptoms to become fully evident before calling for help. Perhaps the most important fact is this: It is not necessary to have been stung many times for a sting to become dangerous. Allergy to hymenoptera venom can also appear after previous stings that had only caused a local reaction. The European Academy of Allergy and Clinical Immunology (EAACI) guidelines explain that systemic reactions to hymenoptera stings have been reported in up to 7.5% of adults and 3.4% of children, with highly variable severity. It is therefore not correct to simply speak of a “venomous sting”. The venom contains proteins capable of acting as allergens: in sensitized people the immune system can recognize them as a threat and massively activate mast cells and basophils, with the release of mediators such as histamine. This is where they can come from widespread hives, swelling, difficulty breathing, bronchospasm, nausea, vomiting, cramps, dizziness, low blood pressure and loss of consciousness. The reaction can develop within minutes.
It’s not just the bumblebee: the risk of Hymenoptera
Hornets, wasps and bees are all hymenopterabut they don’t all have the same poison. In particular, hornets and wasps belong to the Vespid family and have closely related venoms; the bee, however, has a different venom. This is one of the reasons why, after an important reaction, it is useful to arrive at a precise allergy diagnosis and identify, when possible, the responsible insect. The bumblebee also has a characteristic that distinguishes it from the bee: can sting multiple timesbecause its stinger does not normally remain stuck in the skin. It doesn’t mean that every encounter is destined to turn into an emergency, but it makes it especially important to move away from the area quickly if there are multiple insects or a nest present. International recommendations suggest not to wave your arms and not to try to hit the insect: it is better to walk away calmly and reach an enclosed place, especially if there are numerous insects. The risk increases in some conditions. Older age, some cardiovascular or respiratory diseases, a previous systemic reaction, some mast cell diseases and high values of basal tryptasean enzyme produced mainly by mast cells, are among the factors associated with more severe reactions. The specialist literature also indicates that the severity of the reaction cannot be predicted simply by observing how intense a previous sting was. It is also an important distinction because the amount of venom and the immune response are not the same thing. A person can receive a single sting and develop fulminant anaphylaxis; another may receive more than one and have only a local reaction. Multiple stings, however, can become dangerous even without a true allergy, because they increase the overall amount of venom introduced into the body. For this reason, especially when the insects are numerous, an urgent medical evaluation is indicated.
What to do after a sting: time matters
The first thing to do after a sting is move away from the insectto avoid a second exposure. If the reaction remains limited to the affected area, it is possible to wash the area with soap and water and apply cold wrapped in a cloth to reduce pain and swelling. If the stinger is that of a bee and is still visible, it should be removed quickly; Hornets and wasps, however, do not normally leave their stings in the skin. The situation changes completely if they appear difficulty breathing, hoarse voice, swelling of the tongue or throat, widespread hives, dizziness, sudden weakness, fainting, vomiting, or a rapid general deterioration. There is no need to wait for all these symptoms to appear: if signs compatible with anaphylaxis appear after the sting, you should immediately call the 112 and follow the operator’s instructions. For those who have already had a systemic reaction and have a adrenaline auto-injectorthe rule is even more precise: intramuscular adrenaline is the first-line treatment of anaphylaxis and must be used promptly according to the therapeutic plan received. There is no need to wait for antihistamines or cortisone to take effect: these drugs do not replace adrenaline in an anaphylactic emergency. The EAACI recommends the timely use of adrenaline and adequate education of patients at risk. It’s equally important do not stand or walk if anaphylactic shock is suspected. The person must be kept in the most appropriate position for his conditions, generally lying down with his legs raised if tolerated, or with his torso raised if he has serious breathing difficulty; in case of vomiting or loss of consciousness with breathing present, it should be placed on the side. The precise indications must however be followed via 112. The Ministry of Health underlines that, in anaphylaxis, adrenaline is the life-saving drug and that the emergency system must always be activated. The real prevention, however, begins after a major reaction. Anyone who has experienced anaphylaxis after a sting should undergo an allergy evaluation, with appropriate tests to identify the responsible venom and define the risk of re-exposure. For people with systemic allergy to hymenoptera there is in fact a very effective preventive therapy: venom immunotherapycommonly called desensitization. It consists of the controlled administration of progressively increasing quantities of the allergen to drastically reduce the probability of a new serious reaction. According to the EAACI, it is the treatment capable of preventing further systemic reactions to the poison in adults and children with clinical indication. It is here that Manuel Mongini’s story takes on a meaning that goes beyond the news. A puncture in the garden, during a daily activity, can turn into a serious emergency in just a few minutes breathing and circulation. This is no reason to be afraid of every hornet or to turn a sting into a health alert: the risk of death remains very low. But it is a good reason to know the difference between a normal local reaction and anaphylaxis, to know which symptoms not to wait for and, above all, to remember that in allergy to hymenoptera venom, time is not a detail: it is part of the therapy.
