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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 969-972
Wasp sting: An unusual fatal outcome


1 Department of Internal Medicine, Christian Medical College and Hospital, Ludhiana, India
2 Department of Nephrology, Christian Medical College and Hospital, Ludhiana, India
3 Department of Pathology, Christian Medical College and Hospital, Ludhiana, India

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   Abstract 

Wasp stings are not uncommon especially in populations living in proximity of forested areas all over the world. Local manifestations following stings are common and un­usually life threatening anaphylaxis may occur, requiring prompt treatment. Multi organ failure and acute renal failure following wasp stings are rare and histological evaluation suggest acute tubular necrosis secondary to hemolysis, rhabdomyolysis and direct venom toxicity. A rare com­plication of a patient following multiple wasp stings with disseminated intravascular coagulation, acute renal failure and thrombotic microangiopathy is presented.

Keywords: Acute renal failure, Thrombotic microangiopathy, Wasp sting

How to cite this article:
George P, Pawar B, Calton N, Mathew P. Wasp sting: An unusual fatal outcome. Saudi J Kidney Dis Transpl 2008;19:969-72

How to cite this URL:
George P, Pawar B, Calton N, Mathew P. Wasp sting: An unusual fatal outcome. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Dec 5];19:969-72. Available from: http://www.sjkdt.org/text.asp?2008/19/6/969/43474

   Introduction Top


Bees and wasps are associated with painful stings causing intense local reactions. Un­usually they may result in anaphylaxis and death, often under reported due to under recog­nition. [1] Rarely they are associated with fulmi­nant presentations characterized by anaphylaxis, rhabdomyolysis, hemolysis, multiorgan failure and disseminated intravascular coagulation which may occasionally be fatal. [1],[2]


   Case Report Top


A 22- year old woodcutter was stung by nu­merous (described by onlookers as 50-100) wasps while at work in a rural semi forested district in Himachal Pradesh, India. He was stung predominantly on the scalp, face, neck, upper limbs and trunk. Swelling of the face, upper arms and trunk was noticed and he did not have any features of anaphylaxis or hypo­tension. Hydrocortisone and pheneramine ma­leate were administered at a local hospital and 36 hours later the patient presented to our hos­pital for further management. He was anuric at presentation and a previous history of wasp bite could not be confirmed.

At presentation the patient was irritable and restless. His face and arms revealed multiple stings marks but only two stings could be reco­vered from his scalp. Moderate icterus was ob­served without any pedal edema. The swollen areas on the upper arms were tender but no local erythema or raised temperature was ob­served. Systemic examination revealed sca­ttered ronchi and hepatomegaly. Hemodialysis was initiated immediately because of severe metabolic acidosis with hyperkalemia, [Table 1]. The Ig E levels were elevated; however, venom specific Ig E levels and tryptase were not avai­lable to confirm the result. The diagnosis in­cluded disseminated intravascular coagulation (DIC) and rhabdomyolysis with acute renal failure (ARF) secondary to wasp envenoma­tion. The possibility of thrombotic microangio­pathy was looked for daily in view of persis­tent thrombocytopenia but no evidence was seen in closely scrutinized peripheral blood films. Plasmapheresis was withheld due to lack of convincing evidence on its utility. Anemia and coagulopathy was treated with blood, fresh frozen plasma, cryoprecipitate and platelet con­centrate transfusions.

The patient remained anuric and developed multiorgan failure; including rhabdomyolysis, acute renal failure, acute respiratory distress syndrome and suspected hepatic necrosis and coagulopathy, [Table 1]. He died on the ninth hospital day. Post mortem biopsy from the liver, lung and spleen suggested hepatic, pul­monary and splenic congestion. Thrombotic microangiopathy with patchy cortical necrosis was seen on the renal biopsy, [Figure 1].


   Discussion Top


Hymenoptera insects include Apidae (bees) and Vespidae (wasps and hornets) and are fre­quently incriminated in insect bites in forested areas. While local reactions limited to pain and swelling are rarely dangerous, systemic allergic reactions may be mild (local involvement), moderate (angioedema, asthma, abdominal pain) or severe (laryngeal edema, hypotension, loss of conciousness). [1]

A fulminant multisystem response and multi organ failure is usually observed in an indivi­dual previously sensitized to the insect venom [1] 20 years Australian data found wasp sting fatality rate of 0.02% per million population per year, deaths occurring due to anaphylaxis within an hour of being stung. [2] Swedish Regis­try of 10 years duration found fatality inci­dence of 0.2 per million inhabitants and was unrelated to the number of wasp stings. [3] While data on such fatalities is unavailable in India, it is likely to increase with encroachment into forested areas and poor garbage disposal. The aggressive, swarm like attack of wasps against intruders, as seen in this case, has been previously described in Himachal Pradesh, India with Vespa magnifica. [4]

Acute renal failure is rare with wasp bites and may be directly related to the insect venom causing acute interstitial nephritis or indirectly due to massive hemolysis and rhabdomyolysis induced tubular injury. Renal histopathology usually indicate acute tubular necrosis (ATN). [5] Coagulopathy in these patients has been rela­ted to increased levels of anti thrombin [6] and decreased levels of fibrinogen, high molecular weight kininogen, factors V and VIII. [7] Hepatic failure due to centrilobular necrosis, portal tria­ditis and pericholangitis is seen on histopatho­logy. [8] On post mortem renal biopsy of our patient revealed thrombotic microangiopathy, rarely described in patients of wasp bite. [9]

The striking similarity of his clinical presen­tation to snake envenomation, particularly that seen with the Viperidae family, characterized by interaction with blood proteins, platelets, endothelial cells, coagulation cascade and fib­rinolytic pathway was most unusual. DIC plays a major role in snake bite and the presence of fibrin thrombi in glomerular capillaries and renal microvasculature leads to microangiopa­thic hemolytic anemia, thrombocytopenia and cortical necrosis, very similar to our patient. ATN in snake bite is seen to a lesser extent than wasp bites probably due to lesser seve­rity. [10] Bee stings also unusually cause DIC and the role of mesothelial injury, thrombocyte/ macrophage activation, leucotriene/bradykinin/ cytokine release, immune complex deposition in small vessels and complement activation is postulated. [11] Previous exposure and sensitiza­tion to wasp venom could not be ruled out in our patient and was a possible cause of his fulminant presentation. Clinical predictors for anaphylaxis and serious reactions are elusive at the moment. [12]

Early diagnosis and management are crucial and include removal of the stings when possi­ble [13] and the use of intramuscular adrenaline (0.3 mg) followed by chlorphenaramine maleate and hydrocortisone for severe reactions. [1] Opti­mal hydration and alkaline diuresis reduces ischemic ATN and pigment induced tubular injury. Rapidly progressive renal failure and anuria warrant early and intensive dialytic su­pport with reports on satisfactory response and recovery. [5] Plasma exchange has been used with success in isolated case reports. [14] Early presentation to centers with optimal facilities may reduce morbidity and mortality in patients following wasp bites. [13] Furthermore patients with Hymenoptera allergy should be assessed for immunotherapy and instructed to carry adrenaline and use it in the event following a bee sting. [2]

 
   References Top

1.Evan PW. Venom allergy. BMJ 1998;316 (7141):1365-8.  Back to cited text no. 1    
2.McGain F, Harrison J, Winkel KD. Wasp sting mortality in Australia. Med J Aust 2000; 173(4):198-200.  Back to cited text no. 2    
3.Johansson B, Erriksson A, Ornehult L. Human fatalities caused by wasp and bee stings in Sweden. Int J Legal Med 1991;104(2):99-103.  Back to cited text no. 3    
4.Vikrant S, Pandey D, Machhan P, Gupta D, Kaushal SS, Grover N. Wasp envenomation­induced acute renal failure: a report of three cases. Nephrology (Carlton) 2005;10(6):548- 52.  Back to cited text no. 4    
5.Atmaram VP, Mathew A, Kurian G, Unni VN. Acute renal failure following multiple wasp stings. Indian J Nephrol 2005;5:30-2.  Back to cited text no. 5    
6.Rathoff OD, Nossel HL. Wasp sting anaphy­laxis. Blood 1983;61(1):132-9.  Back to cited text no. 6    
7.Smith PL, Kagey-Sobotka A, Bleecker ER, et al. Physiologic manifestations of human anaphylaxis. J Clin Invest 1980;66(5):1072-80.  Back to cited text no. 7    
8.Sakhuja V, Bhalla A, Pereira BJ, Kapoor MM, Bhusnurmath SR, Chugh KS. Acute renal failure following multiple hornet stings. Nephron 1988;49(4):319-21.  Back to cited text no. 8    
9.Chao SC, Lee YY. Acute rhabdomyolysis and intravascular hemolysis following extensive wasp stings. Int J Dermatol 1999;38(2):135-7.  Back to cited text no. 9    
10.Kohli HS, Sakhuja V. Snake bites and acute renal failure. Saudi J Kidney Dis Transpl 2003; 14(2):165-76.  Back to cited text no. 10    
11.Gawlik R, Rymarczyk B, Rogala B. A rare cause of intravascular coagulation after honey bee sting. J Invest Allergol Clin Immunol 2004;14(3):250-2.  Back to cited text no. 11    
12.Singh LR, Singh YT, Singh S, Singh NS, Sharma LR. Acute renal failure in a child following multiple wasp stings. Indian J Nephrol 2005;15:95-7.  Back to cited text no. 12    Medknow Journal
13.Daher Ede F, da Silva Junior GB, Bezerra GP, Pontes LB, Martins AM, Guimaraes JA. Acute renal failure after massive honeybee stings. Rev Inst Med Trop S Paulo 2003;45(1):45-50.  Back to cited text no. 13    
14.Masako M, Hisako H, Eisuke Y, et al. A case of wasp sting disease complicated by multiple organopathy: Capability of lifesaving by early diagnosis for continuous blood filtration and exchange of plasma. Jpn J Clin Exp Med 1999; 76:1355-8.  Back to cited text no. 14    

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Correspondence Address:
Pratish George
Department of Internal Medicine, Christian Medical College and Hospital, Brown Road, Ludhiana-141 008, Punjab
India
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