Key takeaways:

• Insects accounted for 82.7% of cases, followed by food and drugs.
• Yellow jackets (52%), bees (38%) and hornets (9.1%) were the most common insect triggers.
• Only two cases (0.9%) were due to latex.

Perspective from John J. Oppenheimer, MD

Insect venom was the cause of most cases of occupational anaphylaxis, followed by food, drugs and latex, according to a study published in Allergy.

Most of these cases were grade II severity as well, Margitta Worm, MD, professor, division of allergy and immunology, department of dermatology, venereology and allergology, University Hospital Charité in Berlin, and colleagues wrote.

“We wanted to know how often anaphylaxis occurs in a professional setting and what are the most frequent elicitors,” Worm told Healio.

In 2017, an anaphylaxis registry spanning more than 100 specialized tertiary allergy centers in 11 European countries and Brazil began including occupational context in its data.

Between this introduction and March 2023, 225 of 5,851 cases (3.8%) reported to the registry were caused by an occupational allergen, including 214 (95%) where the elicitor was confirmed and 11 (5%) where the elicitor was highly suspected.

The most frequent triggers of occupational anaphylaxis included insects (n = 186; 82.7%), food (n = 27; 12%), drugs (n = 8; 3.6%) and latex (n = 2; 0.9%).

The patients who experienced occupational anaphylaxis had a mean age of 44 years, including 220 (97.8%) who were adults.

One patient died of yellowjacket, and three patients also had a mastocytosis. Severities included grade II (n = 145; 64%), grade III (n = 75; 33%) and grade IV (n = 5; 2.2%).

Professions with the greatest prevalence of occupational anaphylaxis included beekeepers (34%); outdoor workers such as gardeners (19%); food handlers such as employees in restaurants and bakeries, as well as cooks (15%); and farmers (14%).

Bees accounted for 38% of the occupational anaphylaxis cases due to venom and 17% of the non-occupational anaphylaxis cases (P < .001). Wasps caused 52% of the occupational anaphylaxis cases due to venom and 70% of the non-occupational cases (P < .001).

Considering these rates, the researchers advised reducing exposure to venom through the use of protective clothing in addition to considering venom immunotherapy for the duration of the hazardous occupation for patients who experienced severe anaphylaxis.

The occupational anaphylaxis cases caused by food included seven who reacted to peanut, tree nuts and sesame; five who reacted to fruits and vegetables; four who reacted to mussels, shellfish and salmon; five who reacted to rye, wheat and buckwheat flour; four who reacted to meat; and two who reacted to milk. These patterns suggest that PR-10, LTP- and storage proteins were the sensitizing allergens, the researchers said.

Antibiotics triggered five of the eight drug-induced occupational anaphylaxis cases including three cephalosporins, one penicillin and one quinolone. The remaining cases were triggered by a BioNTech Pfizer COVID-19 vaccination, an AstraZeneca COVID-19 vaccination and a gonadotropin-releasing hormone analogon.

Six of these patients were female, which the researchers said could be due to the higher proportion of females who work in hospital settings, and five were admitted to the hospital.

Also, the researchers said they were not surprised that beta lactam antibiotics triggered half of these cases since they are commonly used and are part of the most important elicitor group for drug-induced anaphylaxis.

Whereas there were two cases of anaphylaxis due to latex in this cohort, the researchers noted that it was a major occupational allergen in the 1990s, when sensitization rates ranged from 10% to 15% among health care workers. The researchers attributed this decrease to the introduction of nonpowdered, low protein and synthetic rubber gloves.

Worm called the greater number of food allergy cases and smaller number of latex allergy cases significant.

“This is a novel observation and requires further follow-up,” Worm said.

Despite these findings, the researchers said that additional data would be necessary for better insight into issues specific to individual countries and for the development of optimized protection.

“We will follow up in 5 years to unravel any changes,” Worm said.

Also, Worm said that doctors should be aware that anaphylaxis can be related to work and their patients are exposed to allergens there.

Additionally, she advised beekeepers and other outdoor workers to wear protective clothing.

“When they experience an acute systemic reaction, 911 should be called, and an allergist seen,” she said.

Workers in the food industry and who have jobs related to food should avoid direct skin contact with allergens and wear protective clothing as well, Worm continued, adding that she and her team will be proactive in these efforts.

“We will talk to stakeholders to develop appropriate protection and care programs in at-risk professions,” she said.

For more information:

Margitta Worm, MD, can be reached at margitta.worm@charite.de.

Perspective

As pointed out by the authors, epidemiologic data regarding occupational anaphylaxis are woefully scant. The difficulty in doing such research becomes evident when one considers that the authors began with 5,851 cases with occupational information, but ultimately only 225 (3.8%) anaphylactic episodes were considered to be caused by an occupational allergen.

In light of these small numbers, it is difficult to read too much into these findings. But they are in line with my personal experience in caring for patients with allergy and those who suffer occupational triggering. Physicians should be aware of the jobs that are associated with occupational anaphylaxis and that concomitant atopic disease was observed more frequently among these patients, although this was not significant.

Further research is very much needed. When examining these data derived from more than 5,000 subjects, we are left trying to make sense of very few who actually have occupational anaphylaxis. As an example, we are speaking about only eight patients triggered by medication and only two triggered by latex.

We are really examining very few people with occupational anaphylaxis. It can be very humbling and difficult to make the diagnosis. I once wrote about a patient I cared for who suffered from multiple anaphylactic episodes due to Peruvian lily in a florist’s shop. I was very lucky to have figured it out, but in truth, most of the diagnosis came from listening to a very smart patient