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 Table of Contents 
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 9  |  Page : 5052-5054  

Multi-organ dysfunction following honeybee bite—A rare entity


1 M.D. Medicine, Senior Consultant, Consultant, Tata Main Hospital, Jamshedpur, Jharkhand, India
2 M.D. Medicine, Specialist, Consultant, Tata Main Hospital, Jamshedpur, Jharkhand, India
3 M.D, DNB Medicine, Specialist, Consultant, Tata Main Hospital, Jamshedpur, Jharkhand, India
4 M.D. Medicine, Consultant, Tata Main Hospital, Jamshedpur, Jharkhand, India

Date of Submission16-Apr-2020
Date of Decision10-Jun-2020
Date of Acceptance25-Jun-2020
Date of Web Publication30-Sep-2020

Correspondence Address:
Dr. Sameer Kumar Mehta
House No. 170, 1st Floor, New Sitaramdera, Agrico, Jamshedpur, Jharkhand 831 009
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_629_20

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  Abstract 


Honeybee bites have been known to cause localized allergic reactions and anaphylaxis but systemic toxic reactions leading to multiorgan dysfunction is very rare. Serious complications like acute renal failure, acute myocardial infarction (Kounis syndrome) and even death have been reported as the complication of honeybee bite. Herein, we report a case of multiorgan dysfunction following honeybee bite, which was complicated with acute kidney injury, thrombocytopenia, bradycardia, keratitis, and deranged liver function along with localized allergic reaction and pain.

Keywords: Bradycardia, honeybee, multi-organ dysfunction, thrombocytopenia


How to cite this article:
Prasad SK, Mehta SK, Satyanarayan B, Panda SK. Multi-organ dysfunction following honeybee bite—A rare entity. J Family Med Prim Care 2020;9:5052-4

How to cite this URL:
Prasad SK, Mehta SK, Satyanarayan B, Panda SK. Multi-organ dysfunction following honeybee bite—A rare entity. J Family Med Prim Care [serial online] 2020 [cited 2020 Oct 21];9:5052-4. Available from: https://www.jfmpc.com/text.asp?2020/9/9/5052/296306




  Introduction Top


Honeybee bites are a common public health hazard, the incidence of which is gradually increasing. The bee species causing human envenoming are Apis mellifera mellifera (A. m. mellifera) and A. m. ligustica, and A. m. Scutellata.[1] Massive envenomation is defined as stings more than 50 in number.[2] The clinical manifestations of honey bee bites may be divided into localized reactions, allergic reactions, anaphylaxis, and systemic toxic reactions. Systemic reactions are due to large dose of the venom being injected into the body by a large number of bee bites. Localized reactions include erythema, oedema, and pain whereas allergic reactions triggered by IgE, may cause urticaria, angioedema, bronchoconstriction, and anaphylactic shock. Systemic toxic reactions may cause acute kidney injury (AKI),[3],[4] acute myocardial infarction (Kounis syndrome),[5] stroke,[6] peripheral neuropathy, glomerulonephritis, and even death. Mortality rates in various studies are as high as 15–25 percent.[7] Amongst all the complications, stroke,[6] and multiorgan dysfunction are extremely rare manifestations. The toxic effects of the venom are due to various substances like phospholipase A2, melittin, peptide 401, histamine, hyaluronidase, and apamine. Of these melittin has been found to be the most toxic and is incriminated for most of the severe complications of the bee sting.[8] Allergen-specific immunotherapy has been employed in treatment of insect venom bites to prevent severe allergic reactions. But beta-blockers and ACE inhibitors should be avoided in such patients, as they may worsen allergic reactions.[9]


  Case Summary Top


A 23-year-old male came to the emergency of our hospital with a history of multiple bee bites, two days back. Patient was initially managed at local health center with anti-histaminic and steroids and was discharged after removal of the barbed stingers. He complained of repeated vomiting two days after the bite and got admitted. On examination he was conscious, oriented, afebrile with facial puffiness, congestion of the eyes, pulse-120/min regular, blood pressure-120/80 mmHg and multiple bites all over the body including face and eyelids [Figure 1]. His urine was normal, electrolytes were normal, urinary albumin-creatinine ratio was 42.05. His urine output varied between 1500 and 2500 ml per day. His reports were as follows: [Table 1].
Figure 1: Mutiple bee stings on the face and eyelids

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Table 1: Serial laboratory reports of the patient during his hospital stay

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ECG on day 1 showed sinus tachycardia [Figure 2]. On day 4 of admission, he developed transient bradycardia [Figure 3] which reverted to sinus rhythm spontaneously, the next day. The patient developed multi-organ dysfunction (haematological- thrombocytopenia, acute kidney injury, cardiac rhythm abnormalities, liver dysfunction) and arterial blood gas showed mild metabolic acidosis. He was treated with anti-histaminic, steroids, antibiotics, and intravenous fluids. He then developed keratitis which was treated with topical steroid and atropine eye drops and the sting was removed. He improved with conservative treatment and was discharged on 7th day of admission. On follow-up, he is doing well.
Figure 2: Initial ECG of the patient showing sinus tachycardia

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Figure 3: ECG showing sinus bradycardia

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  Discussion Top


Bee stings commonly cause localized allergic reactions and anaphylaxis but severe systemic toxic reactions can occur, though infrequently. Severity of systemic reactions usually corresponds to the amount of venom injected, which in turn is related to number of bites. Severe systemic complications include acute kidney injury (AKI), acute myocardial infarction, stroke, immune thrombocytopenia, and multiorgan dysfunction syndrome (MODS). Of these, stroke and MODS are very rare. Our case is rare, as the patient had AKI, bradycardia, thrombocytopenia, liver dysfunction, and keratitis apart from the localized allergic reaction. Very few such cases have been reported in literature. Luana FerriaMartin de Toledoet al. had reported a similar case of multiorgan involvement in a 3-year-old child who developed anaphylactic shock, cardiac dysfunction, rhabdomyolysis, and AKI following honeybee bite. Several cases of AKI following bee stings have been reported.[3],[4] Acute kidney injury (AKI) from bee stings is due to multiple factors, such as intravascular hemolysis, rhabdomyolysis, hypotension, and direct toxicity of the venom components (melittin and apamin) to the renal tubules.

Our case also had transient bradycardia which developed 4 days after bee sting. In literature, the association of acute coronary syndrome/myocardial infarction with hymenopteran sting has been called Kounis Syndrome.[5] In a study of 152 patients of honeybee bite done by Laxmegowdaet al., bradycardia was reported in <0.7 percent patients.[7] Our case, though, had only transient bradycardia and did not require pacing. The most likely explanation for bradycardia was a transient spasm of the right coronary artery. Other possible causes of bradycardia and heart block are immune mediated heart block by IgE, action of tetriapine on myocardial potassium channels and apamin-mediated bradycardia.

An elevation of serum creatine phosphokinase and serum lactate dehydrogenase levels was also observed which correlated with muscle damage.

Phospholipase A2 has been incriminated for the hematological manifestations of bee sting and may be the cause of thrombocytopenia in our case. Several cases of immune thrombocytopenia have been reported following honeybee bites.[10]

Our patient also had raised ALT and AST level. Hepatotoxicity in bee bite may be due to the direct effect of the toxin or may be immune mediated and the level of hepatic damage correlates directly with the amount of the venom injected. Liver cell damage due to venom is of the cholangiocellular type.

In a series of 322 cases, only two patients had to be referred to tertiary care center, of whom one had ocular stings. Our case also had ocular stings, which was removed.[6] This case is being reported after getting permission from the institute ethics committee.


  Conclusion Top


This index case is unique in the sense that multiple organ systems were involved and very few cases have been reported. Our patient developed AKI, bradycardia, liver dysfunction, thrombocytopenia, and keratitis. Bradycardia has been found in less than 0.7% cases only. He improved with conservative management and did not require hemodialysis or pacing. We suggest that all patients with multiple honeybee bites should be admitted and kept under observation for 4-7 days to monitor for development of delayed complications. Beta blockers should be avoided in view of the worsening of bradycardia due to bee bite. In the primary care settings, all cases coming with multiple bee bites, a possibility of multi-organ failure should be kept in mind by the primary care physician.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schmidt JO. Clinical consequences of toxic envenomations by Hymenoptera. Toxicon 2018;150:96-104.  Back to cited text no. 1
    
2.
Chen TH, Liao WT, Chen CS, Lin PC, Wu MY. An envenoming syndrome from massive vespa stings induces multiple organ failure. Insects 2020;11:219.  Back to cited text no. 2
    
3.
Ryakitimbo A, Kennedy M, Shao E, Itana ME, Mbwasi R, Kinabo G, et al. Acute kidney injury in a Tanzanian boy following multiple bee stings in resource-limited setting: A case report. Oxford Medical Case Reports 2018;2018:omy070.  Back to cited text no. 3
    
4.
Silva Junior GB, Vasconcelos Junior AG, Rocha AM, Vasconcelos VR, Barros Neto JD, Fujishima JS, et al. Acute kidney injury complicating bee stings–a review. Rev Inst Med Trop São Paulo 2017;59:e25.  Back to cited text no. 4
    
5.
Sunder A, Mohanty B, Singh A. Kounis syndrome: A rare case. J Family Med Prim Care 2020;9:2514.  Back to cited text no. 5
  [Full text]  
6.
Elavarasi A, Haq TM, Thahira T, Bineesh C, Kancharla LB. Acute Ischemic Stroke Due to Multiple Bee Stings_A Delayed Complication. Annals of Indian Academy of Neurology. 2020;23:135.  Back to cited text no. 6
    
7.
Laxmegowda, Ranjith V, Keerthiraj DB, Pradeep BK. Retrospective study on complications of bee sting in a tertiary care hospital. Int J Contemp Med Res 2018;5. doi: 10.21276/ijcmr. 2018.5.7.18.  Back to cited text no. 7
    
8.
Pucca MB, Cerni FA, Oliveira IS, Jenkins T, Timothy P, Argemí LM, et al. Bee updated: Current knowledge on bee venom and bee envenoming therapy. Front Immunol 2019;10:2090.  Back to cited text no. 8
    
9.
InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Insect venom allergies: Short-term and long-term treatment. [Updated 2020 May 7].  Back to cited text no. 9
    
10.
Abdulsalam MA, Ebrahim BE, Abdulsalam AJ. Immune thrombocytopenia after bee venom therapy: A case report. BMC Complement Altern Med 2016;16:107.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]



 

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