Practitioner's Corner
Table. In Vitro Test Resultsa
Death due to Live Bee Acupuncture Apitherapy
Vazquez-Revuelta P, Madrigal-Burgaleta R
Allergy Division, Ramon y Cajal University Hospital, Madrid,
Spain
J Investig Allergol Clin Immunol 2018; Vol. 28(1): 45-46
doi: 10.18176/jiaci.0202
Key words: Apitherapy. Anaphylaxis. Allergy. Hymenoptera. Death.
Palabras clave: Apiterapia. Anafilaxia. Alergia. Himenópteros. Muerte.
Apitherapy is the use of substances from honeybees
(eg, honey, propolis, royal jelly, or even venom), to relieve
various medical conditions. One type of apitherapy is live
bee acupuncture, which involves applying the stinging
bee directly to the relevant sites according to the specific
disease. This practice is often performed in private health
care centers or by nonmedical practitioners. Although
some benefits of apitherapy have been reported, published
evidence of its effectiveness and safety is limited, scarce,
and heterogeneous [1,2]. Most hypersensitivity reactions to
hymenoptera venoms are due to accidental insect stings. Only
a few cases of allergic reactions after acupuncture have been
reported, and most are from areas where traditional medicine
is widely used, such as Korea [1,2].
In sensitized persons, venom compounds can act as
allergens, causing the release of mast-cell mediators and a
spectrum of allergic reactions that can range from mild, local
swelling to severe systemic reactions, anaphylactic shock, or
even death [3]. Furthermore, repeated exposure to the allergen
was found to carry a greater risk of severe allergic reactions
than in the general population [4]. Various adverse reactions
have been reported for apitherapy [2,5].
We report the case of a 55-year-old woman who had been
attending apitherapy sessions every 4 weeks for 2 years with
good tolerance. She decided to receive apitherapy to improve
muscular contractures and stress. She had no clinical record
of any other diseases (eg, asthma, heart disease), other risk
factors, previous reactions of any kind with hymenoptera, or
atopy. During an apitherapy session, she developed wheezing,
dyspnea, and sudden loss of consciousness immediately after
a live bee sting. An ambulance was called, although it took 30
minutes to arrive. The apitherapy clinic personnel administered
methylprednisolone. No adrenaline was available. When
the ambulance arrived, the patient’s systolic pressure had
dropped to 42 mmHg and her heart rate had increased to 110
bpm. Oxygen saturation was not reported. Treatment was
administered immediately and consisted of a double dose
of adrenaline (0.5 mg each), saline infusion, intravenous
corticosteroids, and antihistamines. During transfer to our
hospital, the patient’s blood pressure and heart rate stabilized,
although her Glasgow Coma Scale score was 6; therefore, she
was intubated. At admission, a computed tomography scan
was compatible with watershed stroke, while the results of
© 2018 Esmon Publicidad
45
Total IgE 20 KU/L
Apis mellifera sIgE 5.99 KUA/L
Polistes species <0.35 KUA/L
Vespula species <0.35 KUA/L
rApi m 1 0.54 KUA/L
Basal serum tryptase 8.01 ng/mL
a
Specific IgE assays (ImmunoCAP assay, Phadia)
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
as our allergy department was consulted (Table). In vivo tests
could not be performed because the patient had received
antihistamine and her clinical situation was problematic. The
patient died some weeks later of multiorgan failure. Persistent
hypotension during severe anaphylaxis had caused a massive
watershed stroke and permanent coma with multiorgan
impairment.
To our knowledge, this is the first reported case of death
by bee venom apitherapy due to complications of severe
anaphylaxis in a confirmed sensitized patient who was
previously tolerant.
Previous tolerance to bee stings does not prevent
hypersensitivity reaction; however, repeated exposure favors
a higher risk of sensitization.
Our data enable us to conclude that measures to identify
sensitized patients at risk should be implemented before
each apitherapy sting. Patients should be fully informed of
the dangers of apitherapy before undergoing it. Apitherapy
practitioners should be trained in managing severe reactions
and should be able to ensure they perform their techniques in
a safe environment, with adequate facilities for management
of anaphylaxis and rapid access to an intensive care unit in
order to prevent suboptimal management, such as delays in
treatment (the patient waited 30 minutes before receiving
intramuscular adrenaline). However, these measures may not
be possible. Therefore, the risks of undergoing apitherapy may
exceed the presumed benefits, leading us to conclude that this
practice is both unsafe and unadvisable.
Funding
The authors declare that no funding was received for the
present study.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
References
1. Lim SM, Lee SH. Effectiveness of bee venom acupuncture in
alleviating post-stroke shoulder pain: a systematic review and
meta-analysis. J Integr Med. 2015;13:241-7.
J Investig Allergol Clin Immunol 2018; Vol. 28(1): 42-66
46 Practitioner's Corner
2. Park JH, Yim BK, Lee J-H, Lee S, Kim TH. Risk Associated with
Bee Venom Therapy: A Systematic Review and Meta-Analysis.
PLoS ONE 2005;10:e0126971.
3. Casale TB, Burks AW. Hymenoptera-Sting Hypersensitivity. N
Engl J Med. 2014;370:1432-9.
 Quirce S1
4. Siracusa A, Folletti I, Gerth van Wijk R, Jeebhay MF, Moscato
G, Quirce S, et al. Occupational anaphylaxis - an EAACI task
force consensus statement. Allergy. 2015;70:141-52.
5. Park JS, Lee MJ, Chung KH, Ko DK, Chung H. Live bee
acupuncture (Bong-Chim) dermatitis: dermatitis due to
live bee acupuncture therapy in Korea. Int J Dermatol.
2013;52:1519-24.
Manuscript received April 25, 2017; accepted for publication
September 25, 2017.
Ricardo Madrigal-Burgaleta
Hospital Universitario Ramon y Cajal
Servicio de Alergia
Ctra Colmenar Viejo km 9,100
28034 Madrid, Spain
Email: ricardo.madrigal.md.phd@gmail.com
J Investig Allergol Clin Immunol 2018; Vol. 28(1): 42-66
Dermatitis Caused by Ingestion of Chia Seeds
Tomas-Pérez M1, Entrala A1, Bartolomé B2, Caballero ML1,
1
Department of Allergy, Hospital La Paz Institute for Health
Research (IdiPAZ), Madrid, Spain
2
Roxall España, Bilbao, Spain
J Investig Allergol Clin Immunol 2018; Vol. 28(1): 46-47
doi: 10.18176/jiaci.0203
Key words: Allergy. Chia seed. Dermatitis. IgE. Salvia hispanica.
Palabras clave: Alergia. Semilla de chía. Dermatitis. IgE. Salvia hispanica.
Salvia hispanica, commonly known as chia, is a species
of flowering plant in the mint family, Lamiaceae, that is
native to Guatemala, Paraguay, Bolivia, Argentina, and
central and southern Mexico. The seeds are a source of fiber,
proteins, and w-3 fatty acids. The proteins contained include
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
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