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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2017  |  Volume : 28  |  Issue : 1  |  Page : 196-198
Acute kidney injury due to multiple wasp stings


Department of Nephrology, Gauhati Medical College, Guwahati, Assam, India

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Date of Web Publication12-Jan-2017
 

How to cite this article:
Sharma M, Das HJ, Barman AK, Mahanta PJ. Acute kidney injury due to multiple wasp stings. Saudi J Kidney Dis Transpl 2017;28:196-8

How to cite this URL:
Sharma M, Das HJ, Barman AK, Mahanta PJ. Acute kidney injury due to multiple wasp stings. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Aug 24];28:196-8. Available from: http://www.sjkdt.org/text.asp?2017/28/1/196/198279
To the Editor

Hymenoptera stings can lead to mild to severe allergic reaction as well as various other serious complications. The medically important groups of Hymenoptera are the Apoidea (bees), Vespoidea (wasps, hornets, and yellow jackets), and Formicidae (ants). Hymenopterid stings and subsequent allergic reactions including fatal anaphylaxis are a common indication for emergency department visits worldwide. The incidence of anaphylaxis caused by insect stings has been estimated from 0.3% to 3% in the general population.[1]

Although a few stings generally do not cause any major problem, multiple stings may lead to several complications. Allergic manifestations to wasp stings are well recognized, but more serious complications such as intravascular hemolysis, rhabdomyolysis, thrombocytopenia, acute kidney injury (AKI), liver impairment, and myocardial infarction, and myocarditis are less common.[2] Acute renal failure would occur due to toxic-ischemic-type mechanism as hypovolemia, myoglobinuria, hemoglobinuria, renal ischemia, or direct venom toxicity while patient may develop hypersensitive myocarditis, myocardial infarction, and fetal arrhythmias.[3] Here, we report a case who presented with acute renal failure following multiple wasp stings and was successfully managed.

A 59-year-old male was accidentally stung by multiple wasps over his whole body mainly on his trunk on August 20, 2014. Immediately, after the stings, he noted local pain and mild swelling and was seen at a local healthcare center and managed conservatively. The pain and swelling decreased, but the urine output progressively declined. After four days, he became anuric and developed nausea and vomiting. He was then admitted to a local hospital where he was found to have renal failure. He was referred to our center on August 25, 2014.

On admission, the patient was anuric, had pedal edema and mild pallor. He did not have hypotension, respiratory distress, swelling of lips, cutaneous allergic symptoms such as wheal, urticaria, or pruritus. There was no history of intake of any alternative medicines. On examination, the pulse rate was 80 beats/min; the respiratory rate was 22/min, and the blood pressure 134/82 mm Hg. Local examination showed multiple bite marks (approximately 50-60) all over his body mainly on the torso and face ([Figure 1]). Systemic examination revealed bilateral basal crackles. Initial investigations revealed advanced azotemia and hyperkalemia, and he was given urgent hemodialysis.
Figure 1. Multiple bite marks.

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Hematological investigations on admission revealed the following: a hemoglobin level of 8.9 g/dL, a total leukocyte count of 19,000 cells/mm[3] with 72% polymorphonuclear cells and 26% lymphocytes, a platelet count of 106,000 cells/mm[3], an erythrocyte sedimentation rate of 40 mm/h, a normocytic and normochromic peripheral blood picture without schistocytes, a corrected reticulocyte count of 0.8%, an undetectable plasma hemoglobin, a prothrombin time of 14 s (control 14 s), an activated partial thromboplastin time of 30 s (control 25-32 s), a serum fibrinogen level of 8.8 g/L.

Levels of biochemical parameters were as follows: serum creatinine 9.8 mg/dL, blood urea 170 mg/dL, total proteins 5.7 g/dL, albumin 3.1 g/dL, total bilirubin 0.8 mg/dL, aspartate aminotransferase 50 U/L, alanine aminotransferase 46 U/L, lactate dehydrogenase

320 U/L, alkaline phosphatase 100 U/L, calcium 9.3 mg/dL, inorganic phosphorus 5.6 mg/dL, and CPK 570 U/L. Urinalysis (after the patient had urine output) showed 2+ dipstick proteinuria, no red blood cells (RBCs)/hpf. There were no pus cells or eosinophils. Urine was positive for myoglobin (25 mg/L). Ultrasonography showed kidney sizes of RK 10 cm and LK 10.2 cm with mildly increased echogenecity.

He received alternate-day 4 h bicarbonate hemodialysis for two weeks, at which time the urine output had improved marginally to 300 mL/day. At this time, a kidney biopsy was done ([Figure 2]), which showed severe acute tubular necrosis with interstitial edema, glomerular compartment appeared unremarkable, no significant staining on DIF, and no evidence of renal parenchymal chronicity. Over the next four weeks, his urine output improved gradually, and he became dialysisindependent.
Figure 2. Acute tubular necrosis on renal biopsy.

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At the time of discharge, his serum creatinine was 1.6 mg/dL.

Multiple wasp stings may cause rhabdomyolysis and hemolysis with consequent acute tubular necrosis. Renal failure or death may occur in the range of 20-200 wasp stings and may occur within 4 h to 9 days of stings.[4] In our patients, there was approximately 50-60 stings. Wasp venom contains various biogenic substances including toxic surface active polypeptides (melittin and apamin), enzymes (phospholipase A[2] and hyaluronidase), and low molecular agents (histamine and amino acids). Mellitin and phospholipase are the important components of rhabdomyolysis following a toxic action on striated muscle which also acts on RBC and provoke hemolysis.[5] In rhabdomyolysis, myoglobin released from muscles induces AKI by toxic effect on tubular epithelial cells through intralobular cast nephropathy and pigment nephropathy.[6] In addition, myoglobin is a potent inhibitor of nitric oxide bioactivity and may trigger intrarenal vasoconstriction and ischemia in patients with borderline renal hypoperfusion. Another possible cause of renal insufficiency is acute interstitial nephritis which is thought to occur by direct venom toxicity.[6] ,[7]

In our case, urine positive for myoglobin along with raised creatinine and CPK proved rhabdomyolysis to be the main cause of AKI. Having determined rhabdomyolysis in our case and treating the patient accordingly, we were able to protect renal function as evidenced by decreasing serum creatinine and CPK.

Wasp bite can cause AKI by various mechanism. Early diagnosis and treatment help in improving renal prognosis and also helps in preventing death.

Conflict of interest: None declared

 
   References Top

1.
Reisman RE. Insect stings. N Engl J Med 1994;331:523-7.  Back to cited text no. 1
    
2.
Thiruventhiran T, Goh BL, Leong CL, Cheah PL, Looi LM, Tan SY. Acute renal failure following multiple wasp stings. Nephrol Dial Transplant 1999;14:214-7.  Back to cited text no. 2
    
3.
Nace L, Bauer P, Lelarge P, Bollaert PE, Larcan A, Lambert H. Multiple European wasp stings and acute renal failure. Nephron 1992;61:477.  Back to cited text no. 3
    
4.
Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999;170:223-7.  Back to cited text no. 4
    
5.
Bresolin NL, Carvalho LC, Goes EC, Fernandes R, Barotto AM. Acute renal failure following massive attack by Africanized bee stings. Pediatr Nephrol 2002;17:625-7.  Back to cited text no. 5
    
6.
Islam F, Taimur SD, Kabir CM. Bee envenomation induced acute renal failure in a 8 year old child. Ibrahim Med Coll J 2011;5:34-6.  Back to cited text no. 6
    
7.
Gunasekera WT, Mudduwa L, Lekamwasam S. Acute pigmented tubulopathy and interstitial nephritis following wasp sting. Galle Med J 2008;13:55-6.  Back to cited text no. 7
    

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Correspondence Address:
Manjuri Sharma
Department of Nephrology, Gauhati Medical College, Guwahati, Assam
India
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DOI: 10.4103/1319-2442.198279

PMID: 28098130

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