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Fatal sting reactions are exceedingly rare, but certain factors may entail a considerably higher risk. Delayed administration of epinephrine and upright posture are situational risk factors which may determine an unfavorable outcome of the acute anaphylactic episode and should be addressed during individual patient education. Systemic mastocytosis and senior age are major, unmodifiable long\u2010term risk factors and thus reinforce the indication for venom immunotherapy. Vespid venom allergy and male sex likewise augment the risk of severe or even fatal reactions. Further studies are required to assess the impact of specific cardiovascular comorbidities. Available data regarding potential effects of beta\u2010blockers and\/or ACE inhibitors in coexisting venom allergy are inconclusive and do not justify recommendations to discontinue guideline\u2010directed antihypertensive treatment. The absence of urticaria\/angioedema during sting\u2010induced anaphylaxis is indicative of a severe reaction, serum tryptase elevation, and mast cell clonality. Determination of basal serum tryptase levels is an established diagnostic tool for risk assessment in\n                    <jats:italic>Hymenoptera<\/jats:italic>\n                    venom\u2010allergic patients. Measurement of platelet\u2010activating factor acetylhydrolase activity represents a complementary approach but is not available for routine diagnostic use.\n                  <\/jats:p>","DOI":"10.1111\/all.13945","type":"journal-article","created":{"date-parts":[[2019,6,13]],"date-time":"2019-06-13T12:59:31Z","timestamp":1560430771000},"page":"535-545","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":69,"title":["Risk factors and indicators of severe systemic insect sting reactions"],"prefix":"10.1111","volume":"75","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6681-3192","authenticated-orcid":false,"given":"Johanna","family":"Stoevesandt","sequence":"first","affiliation":[{"name":"Department of Dermatology, Venereology and Allergy &amp; Allergy Center Mainfranken University Hospital W\u00fcrzburg W\u00fcrzburg 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