Studies of coexisting honeybee and vespid-venom sensitivity

Studies of coexisting honeybee and vespid-venom sensitivity Robert E. Reisman, M.D., Ulrich R. MOiler, M.D.,* John I. Wypych, Ph.D., and Mary I. Lazell, B.S. Buffalo, N.Y.

Honeybee and vespid venom-specific lgE were measured by RAST in randomly selected sera of 87 patients who had had anaphylactic reactions after insect stings. Overall there was a poor correlation between the titers of honeybee venom and yellow jacket or hornet venom-specific IgE, Sera from nine patients with high titers of both honeybee venom and yellow jacket venom-specific lgE were selected for RAST-inhibition studies, with these two venoms as coupling and inhibiting antigens. Three patterns of IgE-antibody specificity were detected. Four patients had unique antibody activity with no cross-reactivity between the yellow jacket and honeybee venom-specific igE. This is probably the most common pattern in patients with dual sensitivity. Three patients reacted to a major allergen in yellow jacket venom cross-reacting with a minor allergen in honeybee venom. Their RAST-inhibition patterns demonstrated that the yellow jacket-venom RAST was inhibited by yellow jacket venom only and the honeybee-venom RAST was inhibited by both yellow jacl~et venom and honeybee venom. Two patients had the opposite pattern with honeybee-venom RAST inhibited by honeybee venom only and the yellow jacket RAST inhibited by both honeybee venom and yellow jacket venom. These latter patients reacted to a major allergen in honeybee venom that was cross-reacting with a minor allergen in yellow jacket venom. Studies with rabbit antisera raised to vespid and honeybee venoms demonstrated major antigens that were unique to each family that did not cross-react and several minor cross-reacting antigens. ( J AI..LERGY CLIN IMMUNOL 73:246-252, 1984.)

In the order Hymenoptera, stinging insects are divided into two major families, the vespids, which include yellow jackets, hornets, and wasps and the apids, which include honeybees and bumblebees. For several years our laboratory has been investigating cross-allergenicity among the venoms of these insects. Such studies have great practical implications in view of current recommendations for venom testing and appropriate immunotherapy. Previous studies have focused within the vespid family and may be summarized as follows: (1) Among the different species of yellow jackets, there is extensive cross-reaction with one exception, Vespula squamosa. ~(2) There is extensive cross-reaction between venoms of the two North American hornets, Vespula arenaria (yellow From the AllergyResearchLaboratory,BuffaloGeneralHospital, Depm~nent of Medicine, Division of Allergy, State University of New York at Bufftlo, Buffalo, N,Y. Receivedfor public.~tiortApril 26, 1983. Accqa~d for publication Aug. 22, 1983. Rq~rint requests:RobertE. Reisman, M.D., 50 High St., Buffalo, NY 14203. *Presem~ldr~s: P.D. Dr. M~:I. U. Miillcr, Clmfarzt, Med. Abt. Zieglers~ Bern Posffich2600, 3001 Bern, Switzerland. 246

hornet) and Vespula maculata (bald-faced hornet).2 (3) There is strong eross-allergenicity between yellow jacket and hornet venom. :~ (4) The Polistes wasp is distantly related to other vespid venoms. 4 In this article studies are presented that relate to coexisting honeybee (Apis mellifera) and vespid (yellow jacket)-venom sensitivity. These studies suggest that the majority of patients who react to both yellow jacket and honeybee venoms have IgE antibodies with distinct specificity for each venom. On the other hand, several patients have been identified who have IgE-antibody activity directed to a cross-reacting allergen. Within this latter group two patterns of reactivity have been observed, which suggest that the predominant allergen may be in either yellow jacket or honeybee venom.

MATERIAL AND METHODS Antigens Honeybee, yellow jacket, bald-faced hornet, and yellow hornet ven~ns were collected locally by electrical stimulation. '~The yellow jacket venom was obtained from several species (Vespula maculifrons, Vespula germanica, and Vespula vulgaris) and pooled. Vespid venoms that were

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! J !:.rr !~AST:

Coexisting honeybee and vespiO sensitivity

247

used Radioallergosorbent test

collected by electrical stimulation have biochemical and allergemc properties that are comparable to the commercially avaik~bte venom sac extracts. ~ Vespa orientatis (European hornet) venom was obtained by venom sac puncture and kindly provided by Dr. J. Ishay (Ram-Avid, Israel).

Y

D M

Rabbit lgG antibodies Rabbit antisera to honeybee, yellow jacket, and hornet venoms were prepared as previously described. :~For immunoelectrophoresis, plates of 10 by 8 cm were coated with 12 ml of 1% agarose in acetate buffer, pH 5, 0.025M. The optimal amount of venom was found to be 75/zg. No additional lines were found at lower concentrations. Electrophoresis was run at 10 V/cm for 50 rain in acetate buffer, pH 5, 0.5M. Troughs were filled with 150/xl of respective antisera. lmmunodiffusion was carried out for 24 hr at room temperature in a moist chamber. After this the plates were washed, dried, and stained with 0.2% Coomassie brilliant blue.

Human IgE antibodies measured by RAST Sera were selected at random from 87 patients who had had anaphylactic reactions after insect stings before any specific immunotherapy. Specific-lgE antibodies to honeybee, yellow jacket, and hornet venoms were measured by RAST.; One mg of yellow jacket- or hornet-venom protein or 10 mg of honeybee-venom protein were used to couple 200 cyanogen bromide-activated disks. RAST results were expressed as percent of net binding of a serum pool from ragweed-sensitive patients to ragweed disks. A net binding to the venom disks of 10% was considered significant. The binding of the ragweed standard varied between 11.5% and 12.8% of the total activity added. Background activity that was fbund with normal human serum was 0.7% for the ragweed disks and varied between 0.8% and 1.5% of total activity for the venom disks.

RAST inhibition The RAST-inhibition method was performed as described previouslyY One hundred/xl of serial threefold dilutions of venoms that contained 62.5 to 0.1 tzg venom protein were used for absorption of 100 txl of serum from insect-sensitive patients. All tests were performed in duplicate. Fifty percent inhibition was determined on the basis of a sigmoid curve, which was calculated from 10 individual values by a microcomputer program. Inhibitionexperiments were repeated if the r value of the calculated curve was less than 0.9.

Individual patient case histories and immunologic reactivity Nine patients with high titers of venom-specific IgE that reacted to both honeybee and yellow jacket venoms were

0

FIG. 1. Immunoelectrophoresis of honeybee (B), yellow jacket (Y), bald-faced hornet (M), orientai hornet (()), and yellow hornet (,4) venoms with rabbit antiserum to honeybee venom (abL The anode is to the f,,~,/~;, the cathode to the left.

selected. Their clinical course was reviewed and relented to the results of RAST-inhibition studies with yellow jacket and honeybee venoms as inhibiting and coupling antigens,

RESULTS Rabbit IgG antibodies The cross-antigenicity between honeybee and vespid venoms was studied with rabbit antisera. Fig. 1 demonstrates the immunoelectrophoretic pattern of reaction between a n t i - h o n e y b e e rabbit serum and honeybee, yellow jacket, bald-faced hornet, yellow hornet, and oriental hornet (V. orientcflis) venoms. Multiple lines of precipitation were found between honeybee venom and its antiserum. One or two faint precipitin lines were present with yellow jacket and yellow hornet venoms. One major band was present with V. orientalis venom, and no lines were detected with bald-faced hornet venom. Fig. 2 shows the reaction of rabbit antiserum to yellow jacket venom with the various venoms. Multiple lines of precipitation were found in the reaction with yellow jacket venom, and several precipitin lines were found with the hornet venoms. One line of precipitation that was located at the cathode end was present in the reaction between honeybee venom and yellow j a c k e t - v e n o m anti-serum. In Fig. 3 the reaction of the venoms with a n t i bald-faced hornet venom rabbit serum ;,s shown.

J. ALLERGY CLIN. IMMUNOL.

248

Reisman et al.

FEBRUARY1984

ay B

ay Y

Y

M

0 A FIG. 2. Immunoelectrophoresis of honeybee (B), yellow jacket (Y), bald-faced hornet (M), oriental hornet (O), and yellow hornet (,4) venoms with rabbit antiserum to yellow jacket venom (ay).

FIG. 3. Immunoelectrophoresis of honeybee (B), yellow jacket (Y), bald-faced hornet (M), oriental hornet (0), and yellow hornet fA) venoms with rabbit antiserum to baldfaced hornet venom (am).

Multiple lines of precipitation were found with the hornet and yellow jacket venoms, and several lines were found with honeybee venom. Similar immunoelectrophoretic patterns were found with the reactions between the various venoms and a n t i - y e l l o w hornet venom rabbit serum.

After starting venom therapy, there was a rise in honeybee and yellow jacket venom-specific IgE. RASTinhibition studies with serum that was collected in 1981, at which time the direct RASTs were 66 for honeybee venom and 72 for yellow jacket venom, demonstrated unique antibody activity (Fig. 6). The yellow jacket-venom RAST was inhibited by yellow jacket venom only; the honeybeevenom RAST was inhibited by honeybee venom only. 2. Patient W. P., a 72-year-old man, was examined in 1973 because of a systemic reaction after an insect sting. The insect was not identified. Whole body extract therapy was given from 1974 to 1977. In October 1977 another systemic reaction occurred after a sting on the face. In 1978 positive skin tests and RAST reactions to yellow jacket venom were found. Yellow jacket-venom therapy was started in 1978. Additional stings in 1978 and 1979 were tolerated with no difficulty. Reevaluation in 1981 revealed positive skin tests and RASTs to both honeybee and yellow jacket venoms. Therapy with both venoms was restarted at that time. RAST-inhibition studies that were performed with sera, which was taken on 6/11/81 (BV RAST-39; YJ RAST-64), revealed a pattern similar to the above patient W. S. Honeybee and yellow jacket venom-IgE antibody activity was specific.

Human IgE antibodies, direct PAST Fig. 4 shows the R A S T analysis that compared reactions o f 87 sera picked at random from patients with stinging-insect anaphylaxis with honeybee and yellow jacket venoms. There is poor correlation between these results with an r of only 0.14. Fig. 5 shows similar R A S T comparisons of honeybee and bald-faced hornet venoms. The correlation is somewhat better with an r o f 0.40.

Representative case histories Unique venom specificity. This pattern of reactivity was found in four patients. Representative case histories and immunologic results are as follows: 1. Patient W. S., a 66-year-old man, had an anaphylactic reaction after a yellow jacket sting in 1969. Whole body extract therapy was initiated and continued until 1979. In 1977 dizziness and hypotension occurred after stings from unidentified insects. Skin tests and RAST analysis in December 1979 revealed evidence of honeybee and vespid venom-specific IgE. In the fall of 1979 venom therapy was started with honeybee, yellow jacket, and hornet venoms and has been maintained up to the present time.

Reaction to a major allergen in yellow jacket venom cross-reacting with a minor allergen in honeybee venom.

Three patients were identified with this profile. Representative case histories and immunologic results are as follows: 1. Patient W. D., a 50-year-old man, had an insect sting in August 1980 with no reaction. In October 1980, after two yellow jacket stings, he had a severe acute allergic reaction that was characterized by hypotension, unconsciousness, and shortness of breath. He may have had a myocardial

V O L U M E 73

Coexisting honeybee a~d vespid sensitivity 2 4 9

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FIG. 5. Comparison of the honeybee venom (BI/) and bald-faced hornet (BFHV) RAST titers in randomly selected sera of 87 insect-allergic patients. infarction at that time. Skin tests and RAST analysis in March 1981 revealed high titers of yellow jacket venomspecific IgE (RAST-134) and a significant elevation in honeybee venom-specific IgE (RAST-54). Because of his history therapy was started with yellow jacket venom only. After 3 mo there was a rise in titer of serum honeybee venom-specific [gE (RAST-99), and no change in yellow jacket venom-specific IgE (RAST-141). RAST data are shown in Table I, and inhibition studies are shown in Fig. 7. It should be noted that yellow jacket-venom therapy did lead to a rise in honeybee venom-specific IgE. In the inhibition studies the reaction between W. D. 's serum and yellow jacket venom-coupled disks was inhibited by yellow 9jacket venom only. The reaction between honeybee venom-

10/80 (sting anaphylaxis) 3/2/81 3/20/81 (YJ venom therapy started) 6/1/81

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coupled disks and his serum was inhibited by both yellow jacket and honeybee venoms. 2. Patient S. T., a 15-year-old male a d o l ~ e n t , was initially stung in 1973 by a yellow jacket and developed generalized hives. In 1973, after another insect sting, he was treated immediately with epinephrine. No symptoms occurred. Whole body extract therapy was then given until 1980. In 1978 and 1979 honeybee stings were tolerated with no difficulty. In 1980 anaphylaxis occurred after a yellow jacket sting. In February 1981 skin test and blood studies revealed the presence of both h o n e y ~ venom- and ye~ow jacket venom-specific IgE. Venom immunotherapy with

J. ALLERGYCLIN.IMMUNOL. FEBRUARY1984

250 Reisman et al.

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FIG. 7, RAST-inhibition experiments that demonstrate inhibition of the reaction between serum of patient W. D. and discs coupled with yellow jacket venom and honeybee venom by yellow jacket and honeybee venoms. The results suggest tgE activity that is directed at a major allergen in yellow jacket venom that is cross-reacting with a minor allergen in honeybee venom.

RG. 8. RAST-inhibition experiments that demonstrate inhibition of the reaction between serum of patient T. T. and discs coupled with yellow jacket venom and honeybee venom by yellow jacket venoms. The results suggest IgE-antibody activity that is directed at a major allergen in honeybee venom that is cross-reacting with a minor allergen in yellow jacket venom.

honeybee and yellow jacket venoms was started and has been continued up until the present time. RAST results of sera obtained from 1977 to 1982 are shown in Table II. There was a rise in honeybee venomspecific IgE between 1977 and 1981, which was probably related to the two uneventful honeybee stings, In RAST-inhibition studies the reaction between the patient's serum and yellow jacket venom-coupled disks was inhibited by yellow jacket venom only. The reaction between honeybee venom-coupled disks and the patient's serum was inhibited by both yellow jacket venom and honeybee venom.

RAST-inhibition studies that are shown in Fig. 8 indicated major sensitivity to honeybee venom. His honeybee venom-RAST reaction was inhibited by honeybee venom only. The yellow jacket-venom RAST was inhibited by both honeybee and yellow jacket venoms.

Reaction to a major allergen in honeybee venom crossreacting with a minor allergen in yellow jacket venom. Two

patients have been identified with this pattern. A representative case history is Patient T. T., a 20-year-old man, who was stung in March 1982 by a honeybee. Within a few minutes, he developed generalized urticaria, angioedema, and fatigue. He was given an antihistamine and recovered uneventfully. As there was a honeybee hive in the wall of his house, he had been stung many times in the past but had experienced no difficulty. Subsequent skin tests showed a fairly marked sensitivity to honeybee venom. His honeybeevenom RAST was over 200, which was one of the highest measured in our laboratory. In addition he also had moderate reactivity to yellow jacket venom, which was detected by both skin test and RAST (yellow jacket venom RAST-96).

DISCUSSION

The results of these immunologic studies suggest that there are major unique antigens (allergens) in honeybee and vespid venoms that do not cross-react. In addition there do appear to be cross-reacting allergens, which may be important for specific patients. In the rabbit studies, antiserum that was raised against honeybee venom reacted with multiple lines of precipitation with its homologous antigen and demonstrated only minimal reactivity with yellow jacket and hornet venoms. Rabbit antiserum to yellow jacket venom reacted with multiple lines of precipitation with yellow jacket venom and hornet venom. One line of precipitation was present in the reaction between anti-yellow jacket venom serum and honeybee venom. This line is nonspecific and corresponds to a precipitation reaction that is regularly observed between lipoprotein of mammalian serum and rnelittin. 9 It is no longer'detectable when the isolated

VOLUME 73

",IUMI~ER2

lgG traction of whole antiserum is used. Anti-baldfaced hornet venom antiserum also reacted with multiple lines of precipitation with hornet and yellow jacket venoms. In addition, two lines were found with honeybee venom. The cathodic line again is nonspecific in nature. Similar results were obtained in the immunologic comparison of the phospholipase A present in Hymenoptera insect venoms. ~~In these studies, anti-serum against honeybee-venom phospholipase A inhibited the biochemical activity of the honeybee-venom phospholipase A but had no effect upon the activity of the yellow jacket or hornet-venom phospholipase A. On the other hand, antiserum against bald-faced hornet venom phospholipase A did have some inhibitory effect upon honeybee-venom phospholipase A activity, although not to the same degree as with vespid venoms. In RAST analysis that compared honeybee and yellow jacket venom IgE-antibody titers in sera of stinging insect-allergic patients, there was very little correlation. It appears that in most patients ]gE-antibody activity is directed at either honeybee or yellow jacket venom. Although similar conclusions were reached with the comparison of honeybee and hornet venoms, there was a somewhat better correlation in RAST tilers. These RAST data and rabbit serum immunoelectrophoretic studies might suggest a closer relationship between hornet and honeybee venoms than between yellow jacket and honeybee venoms. Yellow jacket venom was used as the vespid venom in RASTinhibition studies because yellow jackets are the major cause of insect-sting anaphylaxis in the area that was studied. The studies of individual patients who had coexisting elevated titers of honeybee and yellow jacket venom-specific IgE were most interesting. Patients W. S. and W. P. had lgE antibodies with specifichoneybee and yellow jacket venom activity. Both patients had had systemic reactions from insect stings, and both patients had histories of multiple stings from unidentified insects. Thus each may have been exposed to both yellow jackets and honeybees. RASTinhibition studies indicated that the antibody activity was specific for each venom as only the homologous venom inhibited the RAST reactions. These results do not preclude some cross-reactivity among minor allergens. Three patients have been identified who have primar), sensitivity to yellow jacket venom and perhaps secondary sensitivity to honeybee venom. These patients all had acute allergic reactions after yellow jacket stings, had elevated levels of yellow jacket venom-specific IgE, and also had elevated levels of

Coexisting honeybee and_ ves~,;cJ ~ensirivity

:)51

TABLE II. Patient S. T. Results of honeybee and yellow jacket RASTs in sequentiat sera RAST* Date 1972 ( YJ sting anaphylaxis) 1973 (insect sting; no reaction; epinephrine therapy, W B E therapy until 1977) 1977 1978/1979 (HB sting, no reaction) 1980 (YJ sting anaphylaxis) 2/17/81 (HB and YJ venom therapy started) 5/6/81 6/18/81 11/27/81

Yellow jacket

Honeybee

~,)

44

57

42 .~ 34

105

85 52

YJ = yellow jacket; WBE = whole bt~lv extract; FIB -~ h(meybee. *RAST results expressed as percent of u positive ~tandard. Sequential sera examined at the same tinle.

honeybee venom-specific IgE. At least one patient had a history of honeybee stings that were tolerated with no difficulty. Of particular interest was patient S. D. who had arise in honeybee venom-specific IgE after yellow jacket venom therapy without a history of an interval sting. In RAST-inhibition studies, the yellow jacket-venom RAST was inhibited by yellow jacket venom only; the honeybee-venom RAST was inhibited by both honeybee and yellow jacket venom. These results suggest that these patients were sensitive to a major allergen in yellow jacket venom that cross-reacted with a minor allergen in honeybee venom. The rabbit-antibody reactions are quite analogous to this pattern. The third pattern of reactivity was seen in two patients. The patient described had multiple honeybee stings without history of a vespid sting and extremely high titers of honeybee venom-specific lgE. In addition he did show a definite reaction to yellow jacket venom in both RAST and skin tests. In this patient RAST-inhibition studies suggest major sensitivity to honeybee venom. His pattern was opposite to those patients noted above with the honeybee-venom RAST inhibited by honebee venom only and the yellow jacket-venom RAST inhibited by both honeybee and yellow jacket venoms. Thus this patient appeared to be reacting to a major allergen in honeybee venom that cross-reacted with a minor allergen in yellow jacket venom. The theoretical possibility has been proposed that

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252 R e i s m a n et al.

venom immunotherapy could influence these results by sensitizing patients to minor allergens. All nine patients had elevated levels of honeybee and yellow jacket venom-specific IgE at the time of the initial evaluation before any venom immunotherapy. These antibody titers did rise in response to venom injections. Sera were selected for RAST-inhibition analysis because of concomitant high antibody titers. Of the four patients who were found to have specific antibody activity to yellow jacket and honeybee venoms, analysis was done before immunotherapy in two patients and after starting honeybee-venom therapy in one patient and honeybee, yellow jacket, and hornetvenom therapy in one patient. Neither of the two patients with honeybee venom as the major allergen had received venom immunotherapy. Of the three patients with major yellow j a c k e t - v e n o m sensitivity, two had received 3 mo of yellow j a c k e t - v e n o m therapy and one was untreated at the time sera was obtained for RAST inhibition. Thus there is no evidence that venom immunotherapy significantly influenced the conclusions presented in this article. These results add a further complexity to the appropriate treatment of individuals who have insect sting allergy. Current recommendations suggest that patients who have had anaphylactic reactions should be treated with each of the venoms to which they react. Extensive cross-reactivity between the vespid venoms has been reported previously,2..~ and with the appropriate history, the decision of vespid venom therapy may not be difficult. On the other hand most patients have unique antibody activity that is directed at honeybee or vespid venoms. Thus when these patients react to yellow jacket and honeybee venoms, both venoms are usually required for therapy. Results that are presented here indicate that some of these dual reactions may be the result of cross-reactivity. Therapy with inappropriate venom could theoretically lead to sensitization with major allergens. In addition, there are significant economi~ aspects to venom therapy. Unfortunately without the availability of RASTinhibition studies, which are impractical for the numbers of patients who react to both venoms, the physician has almost no choice but to treat with both venoms. If, on the other hand, a history is definitive such as in an individual who has been stung only by honeybees, had had no exposure to yellow jackets, and does react to both venoms, then perhaps honeybee venom would be sufficient therapy. A similar analogy could be made with yellow j a c k e t - v e n o m sensitivity. Specific identification of the cross-reacting allergens will await purification of the major allergens

FEBRUARY 1984

in these venoms. To date at least four allergens have been described in honeybee venom-phospholipase A, hyaluronidase, melittin, and high-molecular-weight substance, probably acid phosphatase.lJ Limited studies have been performed with vespid venoms and suggest that phospholipase, hyaluronidase, another allergen termed "antigen 5 , " and perhaps protease, are major allergens, r,, ~:~When these fractions are present in sufficient quantities, identification of the crossreacting fractions may be possible. REFERENCES

1. Wicher K, Reisman RE, Wypych J, Elliott W, Steger R, Mathews RS, Arbcsman CE: Comparison of the immunogenicity of venoms of various species of yellow jackets (genus Vespula). J ALLERGYCLINIMMUNOL66:244, 1980 2. Mueller U, Elliot( W, Reisman R, lshay J, Walsh S, Steger R, Wypych J, Arbesman CE: Comparison of biochemical and immunologicproperties of venomsof the four hornet species. J ALLERGY CLIN IMMUNOL67:290, 1981

3. Reisman RE, Mueller U, Wypych J, Elliott W, Arbesman CE: Comparison of the allergenicity and antigenicity of yellow jacket and hornet venoms. J ALLERGYCLINIMMUNOL69:268, 1982 4. Reisman RE, Wypych Jl, MueUer UR, Grant JA: Comparison of the allergenicity and antigenicity of Polistes venom and other vespid venoms. J ALLERGYCLIN IMMUNOL70:281, 1982 5. Eskridge EM, Elliott WB, Elliott AH, Eskridge PB, Doerr JC, Schneller N, Reisman RE: Adaptation of the electrical stimulation procedure for the collection of vespid venoms. Toxicon 19:893, 1981 6. Mueller U, Reisman R, Wypych J, Elliott W, Steger R, Walsh S, Arbesman CE: Comparison of vespid venoms collected by electrostimulation and by venom .sac extraction. J ALLERGY CLIN IMMUNOL68:254, 1981

7. Light WC, Reisman RE, Shimizu M, Arhesman CE: Clinical application of measurements of serum levels of bee venomspecific IgE and IgG. J ALLERGYCLINIMMUNOL59:247, 1977 8. Wypych JI, Reisman RE, Elliott WB, Steger RJ, Arbesman CE: Immunologicand biochemical evaluation of the potency of whole insect body extracts. J ALLERGYCLIN IMMUNOL 63:267, 1979 9. Franklin RM, Baer H: Immune and nonimmune gel precipitates produced by honey bee venom and its components (38393). Proc Sac Exp Biol Med 147:585, 1974 10. Nair BC, Nair C, Denne S, Wypych J, Arbesman CE, Elliott WB: Immunologiccomparison of phospholipase A present in Hymenoptera insect venoms. J ALLERGY CLIN IMMUNOL 58:101, 1976 l 1. Reisman RE: Immunologic aspects of Hymenoptera allergy: antigens. In Levine /Vll, Lockey RF, editors: Monograph on insect allergy, American Academy of Allergy and Immunology Committee on Insects. Hartland, WI, 1981, Parker Press of Hartland, p. 25 12. King TP, Sobotka AK, Alagon A, KochoumianL, Lichtenstein LM: Protein allergens of white-faced hornet, yellow hornet, and yellowjacket venoms. Biochemistry. 17:5165, 1978 13. Littler S, Wypych JI, Noble RW, Reisman RE: Allergenic components of bald-faced hornet (V. maculata) venom. J ALLERGY CLIN[MMUNOL 71 (suppl 2):120, 1983