Stinging insects can be an annoying nuisance during outdoor activities. In most individuals, a sting can result in pain, swelling, redness or itchiness at the site. However, for others with a stinging insect allergy, a sting can ultimately prove fatal. Stinging insects include bees, wasps, hornets, yellow jackets and fire ants. Each of these insects produce venom, and sting to defend themselves or their nests. Typically, yellow jackets, hornets and wasps are aggressive and sting when agitated. Bumblebees are beneficial to the environment and actually try to avoid human contact. If they feel threatened however, and cannot escape, they will sting. Honeybees are also docile, avoid humans, and leave their stinger behind during a sting, leading to their own death. Imported red and black fire ants are aggressive and have invaded a large portion of the southern United States, becoming a major menace. According to the American College of Allergy, Asthma and Immunology, severe allergic reactions to insect stings occur in an estimated 0.4 to 0.8% of children and 3% of adults. At least 50 deaths occur in the U.S. each year due to stinging insect allergy. Patients allergic to stinging insects develop an exaggerated immune response to venom. These individuals produce IgE antibodies (allergic antibodies) to specific insect venom. Once a sting occurs, these antibodies bind to the venom proteins and activate allergic cells to release chemicals such as histamine, potentially causing anaphylaxis. Anaphylaxis is a severe and potentially life-threatening allergic reaction. Symptoms include hives; flushing of the skin; lip, tongue or throat swelling; coughing; wheezing; difficulty breathing; vomiting; dizziness; low blood pressure; and collapse. Immediate emergency medical care is required for these symptoms and a delay in treatment can be fatal. All patients who have had a severe allergic reaction to venom must carry an epinephrine auto injector. In the event of a severe sting reaction, inject epinephrine immediately and call 911. Epinephrine only temporarily reverses symptoms until emergency medical care can be established. If a stinger was left in the skin during a sting, it should be removed quickly to limit the amount of venom expelled. The stinger should not be squeezed, as this will extract more venom. Instead, it should be flicked off with a credit card or fingernail or pulled off with tape. Patients with severe stinging insect allergy should stay away from threatening insects. As mentioned earlier, many of these insects can be aggressive. Patients should not walk barefoot outdoors and should avoid loose clothing that can trap insects between their clothing and skin. Sweet smells, such as perfume, and brightly colored clothing can attract insects and should also be avoided. Take caution with food and sugary drinks, which will invite insects to the area. Keep your food and drinks covered, and be careful when drinking from cans, as insects can be hiding inside. Any nests near the home should be removed. A board-certified allergist must evaluate patients with a history of a severe insect sting reaction. The risk of repeat severe sting reactions is quite high, and thus measures must be taken to reduce the risk. An allergist will perform testing, including both blood analysis, known as RAST testing, and skin-prick testing. These tests will determine the stinging insect(s) to which the patient is allergic. Venom allergen immunotherapy (commonly known as allergy shots) is then recommended. Typically, venom immunotherapy involves weekly injections of the actual allergenic venom. Initially, concentrations of the venom are very diluted, and are increased gradually over time. The total duration of shot therapy is several years, resulting in the patient’s desensitization to the venom. Venom allergen immunotherapy is 75 to 98% effective in preventing future severe sting reactions. Severe stinging insect allergy can be frightening. However, by making best efforts to avoid these insects, carrying emergency medications, and developing a treatment plan with an allergist, patients with insect allergy can still enjoy the great outdoors.