Unusual Reactions to Hymenoptera Stings: What Should we Keep in Mind?

Multiple Bee Stings and Acute Kidney Injury: A Case Report

Acute kidney injury (AKI) is a common complication following multiple honey bee stings and usually presents after 24-48 hours following the incidence. The severity of AKI is related to the number of stings. A single sting can cause an allergic reaction, and as the stings increase, a higher amount of venom is inoculated, leading to systemic poisoning. Bee venom can have direct or indirect effects on the kidneys. AKI is a combination of toxic and ischemic acute tubular necrosis. Patients may require dialysis, and the usual renal recovery time is 4-120 days. The patient with multiple honey bee stings needs emergency medical treatment, sometimes in the ICU setting, with the aim of treating or preventing anaphylaxis reactions. A case of AKI due to multiple honey bee stings is presented, which is rare but a known occurrence. The patient survived with a recovery of renal function.

Relapsing nephrotic syndrome with acute renal failure following a unique episode of multiple bee stings: A case report

The commonest renal involvement after bee stings is acute kidney injury due to rhabdomyolysis. Nephrotic syndrome combined with AKI is unusual complication of Hymenoptera stings. We diagnosed a minimal change disease and six-year follow up relapses.

Pulmonary involvement from animal toxins: the cellular mechanisms

Venomous animals and their venom have always been of human interest because, despite species differences, coevolution has made them capable of targeting key physiological components of our bodies. Respiratory failure from lung injury is one of the serious consequences of envenomation, and the underlying mechanisms are rarely discussed. This review aims to demonstrate how toxins affect the pulmonary system through various biological pathways. Herein, we propose the common underlying cellular mechanisms of toxin-induced lung injury: interference with normal cell function and integrity, disruption of normal vascular function, and provocation of excessive inflammation. Viperid snakebites are the leading cause of envenomation-induced lung injury, followed by other terrestrial venomous animals such as scorpions, spiders, and centipedes. Marine species, particularly jellyfish, can also inflict such injury. Common pulmonary manifestations include pulmonary edema, pulmonary hemorrhage, and exudative infiltration. Severe envenomation can result in acute respiratory distress syndrome. Pulmonary involvement suggests severe envenomation, thus recognizing these mechanisms and manifestations can aid physicians in providing appropriate treatment.

Extracorporeal membrane oxygenation support in refractory anaphylactic shock after bee stings: A case report

An allergy to insect stings is one of the most frequent causes of anaphylactic reactions. Such reactions can be fatal, even on the first reaction, although it very rarely happens. The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) in refractory anaphylactic shock was previously described. We report a case of a 31-year-old female who presented with refractory anaphylactic shock after bee stings without the presence of cutaneous manifestations other than the rashes in her neck. The toxic component of bee venom and systemic allergic response plays a vital role in pathophysiology. She did not respond to conventional advanced life support, but following urgent VA ECMO, she survived neurologically intact. Despite an uncommon indication for anaphylaxis, ECMO support may be possible and effective in patients with refractory shock.

A Case Report of Anaphylactic Shock Due to Hornet Sting with Multiple Organ Dysfunction Complications

BACKGROUND: Hornet venom has been recognized to induce lethal systemic effects such as anaphylaxis shock, bronchospasm, acute kidney or liver injury, disseminated intravascular coagulation (DIC), cardiovascular collapse, and even death. It consists of several enzymes and polypeptides with low molecular weights. It has been reported to contain the enzymes phospholipase A2, hyaluronidase, phosphomonoesterase acid ester, α-D-glucosidase, lysophospholipase, α-galactosidase, α-acetylamino-deoxsiglucosidase, and arylamidase. The venom will cause localized or systemic inflammation, an anticoagulant effect that may be fatal. CASE REPORT: Herewith, a survival case report suffered from DIC with multi-organ failure following severe anaphylaxis shock post a hundred or massive Hornet sting. CONCLUSION: We have reported a case of anaphylactic shock after a massive hornet sting with DIC that presented symptoms of shock, AKI, ALI, and multi-site bleeding. Although the mortality rate for similar cases is quite high, the outcome will be better with comprehensive and adequate treatment.

Ant sting-induced whole-body pustules in an inebriated male: A case report

BACKGROUND

Many ant species can harm humans; however, only a few cause life-threatening allergic reactions. Normally, reactions caused by ants occur in patients who come into contact with ant venom. Venom contains various biologically active peptides and protein components, of which acids and alkaloids tend to cause anaphylaxis. Ant venom can cause both immediate and delayed reactions. The main histopathological changes observed in ant hypersensitivity are eosinophil recruitment and Th2 cytokine production.

CASE SUMMARY

A 70-year-old man was bitten by a large number of ants when he was in a drunken stupor and was hospitalized at a local hospital. Five days later, because of severe symptoms, the patient was transferred to our hospital for treatment. Numerous pustules were observed interspersed throughout the body, with itching and pain reported. He had experienced fever, vomiting, hematochezia, mania, soliloquy, sleep disturbances, and elevated levels of myocardial enzymes since the onset of illness. The patient had a history of hypertension for more than 1 year, and his blood pressure was within the normal range after hypotensive drug treatment. He had no other relevant medical history. Based on the clinical history of an ant bite and its clinical manifestations, the patient was diagnosed with an ant venom allergy. The patient was treated with 60 mg methylprednisolone for 2 d, 40 mg methylprednisolone for 3 d, and 20 mg methylprednisolone for 2 d. Oral antihistamines and diazepam were administered for 12 d and 8 d, respectively. Cold compresses were used to treat the swelling during the process. After 12 d of treatment, most pustules became crusts, whereas some had faded away. No symptoms of pain, itching, or psychological disturbances were reported during the follow-up visits within 6 mo.

CONCLUSION

This case report emphasizes the dangers of ant stings.

What We Know about Sting-Related Deaths? Human Fatalities Caused by Hornet, Wasp and Bee Stings in Europe (1994-2016)

Simple Summary

Information about fatalities due to stinging insects is scarce. Hymenopteran-related deaths (n = 1691) in 32 European countries based on official registers over a 23-year period (1994–2016) are described. Male adults (25–64 years) were the most common group to be fatally injured and almost half of the fatalities were recorded at “unspecified places”. Fatalities per million inhabitants per year ranged from 0 to 2.24 with an average of 0.26. Geographic, environmental, and ecological factors influence the frequency of stings, and its subsequent reaction. It is necessary to produce and interpret knowledge using diverse sources and in an interdisciplinary way. As part of the One Health philosophy, people and hornets, wasps and bees, as well as the environment that they share are closely connected.

Abstract

Epidemiology of Hymenopteran-related deaths in Europe, based on official registers from WHO Mortality Database (Cause Code of Death: X23), are presented. Over a 23-year period (1994–2016), a total of 1691 fatalities were recorded, mostly occurring in Western (42.8%) and Eastern (31.9%) Europe. The victims tended to concentrate in: Germany (n = 327; 1998–2015), France (n = 211; 2000–2014) and Romania (n = 149; 1999–2016). The majority of deaths occurred in males (78.1%) between 25–64 years (66.7%), and in an “unspecified place” (44.2%). The highest X23MR (mortality rate) were recorded in countries from Eastern Europe (0.35) followed by Western (0.28), Northern (0.23) and Southern Europe (0.2). The countries with the highest and lowest mean X23MR were Estonia (0.61), Austria (0.6) and Slovenia (0.55); and Ireland (0.05), United Kingdom (0.06) and the Netherlands (0.06), respectively. The X23 gender ratio (X23GR; male/female) of mortality varied from a minimum of 1.4 for Norway to a maximum of 20 for Slovenia. Country-by-country data show that the incidence of insect-sting mortality is low and more epidemiological data at the regional level is needed to improve our understanding of this incidence. With the expansion of non-native Hymenopteran species across Europe, allergists should be aware that their community’s exposures are continually changing

Unusual Reactions to Hymenoptera Stings: Current Knowledge and Unmet Needs in the Pediatric Population

Hymenoptera stings are generally well-tolerated and usually cause limited local reactions, characterized by self-resolving erythema and edema associated with pain. However, Hymenoptera stings can induce immediate and delayed hypersensitivity reactions. In addition to these manifestations, unusual reactions to Hymenoptera stings have been reported. The latter are defined as unusual because of their atypical characteristics. They may differ from classical hypersensitivity reactions due to the stings' particular localization and the unusual involvement of one or more specific organs. Although unusual reactions to Hymenoptera stings are infrequent, it is essential for clinicians to know the possible related clinical manifestations. Here, we review the available literature and propose a diagnostic and management algorithm. At present, there are no defined guidelines for most of the unusual reactions to Hymenoptera stings, which should be managed in a tailored way according to the specifical clinical manifestations presented by the patients. Further studies are needed to better define these conditions and the underlying pathogenetic mechanisms to improve the diagnostic and therapeutic approach.

Visual Loss Caused by Central Retinal Artery Occlusion After Bee Sting: A Case Report

A bee sting can lead to an extremely rare case of visual loss caused by central retinal artery occlusion (CRAO). In this study, we report a 66-year-old healthy woman who was referred to our Eye Center because of visual loss, which had occurred after bee sting 2 days earlier. The visual acuity was no light perception (NLP). Examination revealed left eyelid edema, conjunctiva congestion, a 6-mm fixed pupil, scattered retinal hemorrhage, and white-appearing ischemic retina with one small area of the normal-appearing retina temporal to the optic disk. Fundus fluorescein angiography revealed CRAO with one cilioretinal artery sparing. Her systemic workup revealed hypersensitivity, hypercoagulable state, myocardial damage, and hepatic damage. After topical and systemic treatments, the visual acuity was still NLP with improved systemic workup. In brief, CRAO may occur after bee sting, and visual acuity should be monitored for early diagnosis.

Global View on Ant Venom Allergy: from Allergenic Components to Clinical Management

Hymenoptera venom allergy is characterised by systemic anaphylactic reactions that occur in response to stings from members of the Hymenoptera order. Stinging by social Hymenoptera such as ants, honeybees, and vespids is one of the 3 major causes of anaphylaxis; along with food and drug exposure, it accounts for up to 43% of anaphylaxis cases and 20% of anaphylaxis-related fatalities. Despite their recognition as being of considerable public health significance, stinging ant venoms are relatively unexplored in comparison to other animal venoms and may be overlooked as a cause of venom allergy. Indeed, the venoms of stinging ants may be the most common cause of anaphylaxis in ant endemic areas. A better understanding of the natural history of venom allergy caused by stinging ants, their venom components, and the management of ant venom allergy is therefore required. This article provides a global view on allergic reactions to the venoms of stinging ants and the contemporary approach to diagnose and manage ant venom allergy.

Clinical effects and factors associated with adverse clinical outcomes of hymenopteran stings treated in a Thai Poison Centre: a retrospective cross-sectional study

OBJECTIVE

To describe clinical effects and outcomes of hymenopteran stings and to explore the non-laboratory factors associated with adverse clinical outcomes, a composite outcome including death, respiratory failure requiring intubation, acute kidney injury (AKI) requiring dialysis and hypotension requiring vasopressor use.

METHODS

A retrospective cross-sectional study was performed at the Ramathibodi Poison Center, a poison centre of a tertiary care hospital in Thailand. All cases of hymenopteran sting consultations from January 2015 to June 2019 were consecutively enrolled, and charts were reviewed. Demographics, initial clinical characteristics and outcomes were collected. Factors associated with adverse clinical outcome were explored.

RESULTS

One hundred and fourteen hymenopteran stings cases (wasp 48%, bee 33%, hornet 14% and carpenter bee 8.8%) were included (median age, 36.5 years (interquartile range 9-55); male 63%). The prevalence of adverse clinical outcomes was 12.3% (95%CI 6.88-12.8). At initial presentation, 100% of cases had local skin reactions, 11.4% were clinical anaphylaxis, and 8% had red urine. Adverse clinical outcomes included death (n = 10), respiratory failure requiring intubation (n = 9), AKI requiring dialysis (n = 6) and hypotension requiring vasopressor use (n = 2). None of the patients with carpenter bee or hornet stings developed adverse clinical outcomes. In univariable analysis, urticaria, wheezing, red urine, wasp sting and sting number > 10 were significantly associated with adverse clinical outcomes. In multivariable analysis, red urine (adjusted OR 11.1 (95% CI 1.57-216)), wheezing (adjusted OR 16.7 (95% CI 1.43-402)) and a number of stings > 10 (adjusted OR 21.5 (95% CI2.13-2557)) were significant.

CONCLUSIONS

Adverse clinical outcomes in hymenopteran stings were not uncommon among cases inquiring to a national Thai poison centre. At initial presentation, red urine, wheezing and a number stings >10 were significantly associated with adverse clinical outcomes. Larger epidemiologic studies are required to confirm these associations.

Idioventricular rhythm and shock after a honeybee sting

OBJECTIVE

The objective of this study was to describe the case of a 19-year-old male presenting with bradycardia and hypotension after a honeybee sting making a review of the literature and pathophysiology of the cardiovascular and electrocardiogram (EKG) changes after a bee sting.

METHODS

The patient's airway was inspected and secured. Electrocardiogram with an idioventricular rhythm at 41' bpm. Oxygen was administered, an intravenous access was established, and the transcutaneous pacemaker leads were placed on the chest of the patient, then published guidelines management was induced.

RESULTS

The EKG showed idioventricular rhythm at a rate of 41 beats/min that resolved to a normal sinus rhythm after treatment.

CONCLUSIONS

A full and prompt cardiovascular evaluation should be performed in all patients presenting to the emergency department after a bee sting, and published guidelines regarding the management of bradycardia and anaphylaxis should be followed to achieve successful outcomes.

Precision Medicine in Hymenoptera Venom Allergy: Diagnostics, Biomarkers, and Therapy of Different Endotypes and Phenotypes

Allergic reactions to stings of Hymenoptera species may be severe and are potentially fatal deviations of the immunological response observed in healthy individuals. However, venom-specific immunotherapy (VIT) is an immunomodulatory approach able to cure venom allergy in the majority of affected patients. An appropriate therapeutic intervention and the efficacy of VIT not only depend on a conclusive diagnosis, but might also be influenced by the patient-specific manifestation of the disease. As with other diseases, it should be borne in mind that there are different endotypes and phenotypes of venom allergy, each of which require a patient-tailored disease management and treatment scheme. Reviewed here are different endotypes of sting reactions such as IgE-mediated allergy, asymptomatic sensitization or a simultaneous presence of venom allergy and mast cell disorders including particular considerations for diagnosis and therapy. Additionally, phenotypical manifestations of venom allergy, as e.g. differences in age of onset and disease severity, multiple sensitization or patients unsusceptible to therapy, are described. Moreover, biomarkers and diagnostic strategies that might reflect the immunological status of the patient and their value for therapeutic guidance are discussed. Taken together, the increasing knowledge of different disease manifestations in venom hypersensitivity and the growing availability of diagnostic tools open new options for the classification of venom allergy and, hence, for personalized medical approaches and precision medicine in Hymenoptera venom allergy.

Comparison of Clinical Manifestations, Treatments, and Outcomes between Vespidae Sting and Formicidae Sting Patients in the Emergency Department in Taiwan

Background: Hymenopteran stings are the most common animal insult injury encountered in the emergency department. With increasing global spread of imported fire ants in recent decades, the rate of Formicidae assault has become a serious problem in many countries. Formicidae-associated injuries gradually increased in Taiwan in recent decades and became the second most common arthropod assault injury in our ED. The present study aimed at comparing the clinical characteristics of Formicidae sting patients with those of the most serious and common group, Vespidae sting patients, in an emergency department (ED) in Taiwan. Methods: This retrospective study included patients who were admitted between 2015 to 2018 to the ED in a local teaching hospital in Taiwan after a Vespidae or Formicidae sting. Cases with anaphylactic reaction were further compared. Results: We reviewed the records of 881 subjects (503 males, 378 females; mean age, 49.09 ± 17.62 years) who visited our emergency department due to Vespidae or Formicidae stings. A total of 538 (61.1%) were categorized into the Vespidae group, and 343 (38.9%) were sorted into the Formicidae group. The Formicidae group had a longer ED length of stay (79.15 ± 92.30 vs. 108.00 ± 96.50 min, p < 0.01), but the Vespidae group had more cases that required hospitalization (1.9% vs. 0.3%, p = 0.04). Antihistamines (76.8% vs. 80.2%, p < 0.01) were more frequently used in the Formicidae group, while analgesics were more frequently used in the Vespidae group (38.1% vs. 12.5%, p < 0.01). The Vespidae group had more local reactions, and the Formicidae group had more extreme, systemic, or anaphylactic allergic reactions. Creatine kinase was significantly higher in the Vespidae group with an anaphylactic reaction. Sting frequency in both groups exhibited the same positive associations with average temperature of the month and weekend days. Conclusion: Formicidae sting patients presented to the ED with higher rate allergic reactions and spent more time in the ED than Vespidae sting patients. However, Vespidae sting patients had more complications and higher rates of admission, especially with anaphylactic reaction. Laboratory data, especially creatine kinase data, were more valuable to check in Vespidae sting patients with an anaphylactic reaction in the ED. Both groups exhibited positive correlations with temperature and a higher rate on weekend days.

A Case Report on Rhabdomyolysis After Multiple Bee Stings

Envenoming syndrome is an uncommon condition associated with significant morbidity and mortality following multiple Hymenoptera stings. We review the case of a 90-year-old male who presented after receiving greater than 100 bee stings and was found to have rhabdomyolysis with concomitant acute kidney injury. Physicians should consider envenoming syndrome in all patients presenting with greater than 50 bee stings, despite hemodynamically stability upon initial presentation. 

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

A Case of Conjunctival Bee Sting Injury with Review of the Literature on Ocular Bee Stings

BACKGROUND Ocular bee stings have been rarely described in the literature, and their management is controversial. A case of conjunctival bee sting with retention of the stinger for 48 hours is presented with a review of the literature on the complications and management of ocular bee sting injury. CASE REPORT A 22-year-old beekeeper presented to the Emergency Department with mild symptoms from a conjunctival bee sting that he had received 48 hours previously. The stinger was removed in the Emergency Department, and topical antibiotic and anti-inflammatory treatment with corticosteroid were given. There were no complications in this case. However, review of the literature has shown that although the outcome from ocular bee stings can be mild, as in this case, ocular bee stings can result in severe visual symptoms that require amniotic membrane transplant (AMT). Management commonly includes removal of the stinger and both topical and systemic treatment with corticosteroids. The main complications include cataracts, inflammation of the anterior chamber, optic neuropathies, and changes in ocular pressure. CONCLUSIONS Ocular bee stings have been rarely described in the literature, and the management remains controversial. As this case has shown, removal of the stinger and the use of topical treatment with antibiotics and corticosteroids can prevent potentially serious complications that may affect vision. Early and regular follow-up with ocular imaging may be required when symptoms persist.

The kiss of (cell) death: can venom-induced immune response contribute to dermal necrosis following arthropod envenomations?

Introduction: Snakes, insects, arachnids and myriapods have been linked to necrosis following envenomation. However, the pathways involved in arthropod venom-induced necrosis remain a highly controversial topic among toxinologists, clinicians and the public. On the one hand, clinicians report on alleged envenomations based on symptoms and the victims' information. On the other hand, toxinologists and zoologists argue that symptoms are incompatible with the known venom activity of target species. This review draws from the literature on arthropod envenomations, snakebite, and inflammatory processes to suggest that envenomation by a range of organisms might trigger an intense inflammatory cascade that ultimately lead to necrosis. If confirmed, these processes would have important implications for the treatment of venom-induced necrosis. Objectives: To describe two inflammatory pathways of regulated necrosis, tumour necrosis factor (necroptosis) and Neutrophil Extracellular Traps (NETosis); to discuss existing knowledge about snake venom and arachnid-induced necrosis demonstrating the involvement of tumour necrosis factor and neutrophils in the development of tissue necrosis following envenomation and to contribute to the understanding of venom-induced necrosis by arthropods and provide clinicians with an insight into little known inflammatory processes which may occur post envenomation. Methods: ISI Web of Science databases were searched using the terms "spider bite necrosis", "arthropod envenomation necrosis", "venom necrosis", "venom immune response", "loxoscelism", "arachnidism", "necroptosis venom", "necroptosis dermatitis", "tumour necrosis factor TNF venom", "scorpionism", "scolopendrism", "centipede necrosis", "NETosis venom", "NETosis necrosis". Searches produced 1737 non-duplicate citations of which 74 were considered relevant to this manuscript. Non-peer-reviewed sources or absence of voucher material identifying the organism were excluded. What is necrosis? Necrosis is the breakdown of cell membrane integrity followed by inflowing extracellular fluid, organelle swelling and the release of proteolytic enzymes into the cytosol. Necrosis was historically considered an unregulated process; however, recent studies demonstrate that necrosis can also be a programmed event resulting from a controlled immune response (necroptosis). Tumour necrosis factor and the necroptosis pathway: Tumour necrosis factor is a pro-inflammatory cytokine involved in regulating immune response, inflammation and cell death/survival. The pro-inflammatory cytokine TNF-α participates in the development of necrosis after envenomation by vipers. Treatment with TNF-α-antibodies may significantly reduce the manifestation of necrosis. Neutrophil Extracellular Traps and the NETosis pathway: The process by which neutrophils discharge a mesh of DNA strands in the extracellular matrix to entangle ("trap") pathogens, preventing them from disseminating. Neutrophil Extracellular Traps have been recently described as important in venom-induced necrosis. Trapped venom accumulates at the bite site, resulting in significant localized necrosis. Arthropod venom driving necrosis: Insects, myriapods and arachnids can induce necrosis following envenomation. So far, the processes involved have only been investigated in two arachnids: Loxosceles spp. (recluse spiders) and Hemiscorpius lepturus (scorpion). Loxosceles venom contains phospholipases D which hydrolyse sphingomyelin, resulting in lysis of muscle fibers. Subsequently liberated ceramides act as intermediaries that regulate TNF-α and recruit neutrophils. Experiments show that immune-deficient mice injected with Loxosceles venom experience less venom-induced inflammatory response and survive longer than control mice. Necrosis following Hemiscorpius lepturus stings correlates with elevated concentrations of TNF-α. These observations suggest that necrosis may be indirectly triggered or worsened by pathways of regulated necrosis in addition to necrotic venom compounds. Conclusions: Envenomation often induce an intense inflammatory cascade, which under certain circumstances may produce necrotic lesions independently from direct venom activity. This could explain the inconsistent and circumstantial occurrence of necrosis following envenomation by a range of organisms. Future research should focus on identifying pathways to regulated necrosis following envenomation and determining more efficient ways to manage inflammation. We suggest that clinicians should consider the victim's immune response as an integral part of the envenomation syndrome.

Acute kidney injury in a Tanzanian boy following multiple bee stings in resource-limited setting: a case report

Bee sting has been identified as among causative agents of nephrotoxic acute tubular necrosis which may lead to acute kidney injury. Bee envenomation has medicinal properties but when a higher dose is inoculated may cause severe anaphylaxis with very poor prognosis. We report a 12-year-old boy with acute kidney injury following multiple bee stings who recovered well after hemodialysis.

A membrane disrupting toxin from wasp venom underlies the molecular mechanism of tissue damage

The molecular mechanism of the local hypersensitivity reactions to wasp venom including dermal necrosis remains an enigma regardless of the numerosity of the reported cases. In this study, we discovered a new membrane disrupting toxin, VESCP-M2 responsible for tissue damage symptoms following Vespa mandarinia envenomation. Electrophysiological assays revealed a potent ability of VESCP-M2 to permeate the cell membrane whereas in vivo experiments demonstrated that VESCP-M2 induces edema, pain and dermal necrosis characterized by the presence of morphological and behavioral phenotypes, pro-inflammatory mediators, biomarkers as well as the disruption of dermal tissue. This study presents the molecular mechanism and symptom-related function of VESCP-M2 which may form a basis for prognosis as well as therapeutic interventions.

Comparative antennal transcriptome of Apis cerana cerana from four developmental stages

Apis cerana cerana, an important endemic honey bee species in China, possesses valuable characteristics such as a sensitive olfactory system, good foraging ability, and strong resistance to parasitic mites. Here, we performed transcriptome sequencing of the antenna, the major chemosensory organ of the bee, using an Illumina sequencer, to identify typical differentially expressed genes (DEGs) in adult worker bees of different ages, namely, T1 (1 day); T2 (10 days); T3 (15 days); and T4 (25 days). Surprisingly, the expression levels of DEGs changed significantly between the T1 period and the other three periods. All the DEGs were classified into 26 expression profiles by trend analysis. Selected trend clusters were analyzed, and valuable information on gene expression patterns was obtained. We found that the expression levels of genes encoding cuticle proteins declined after eclosion, while those of immunity-related genes increased. In addition, genes encoding venom proteins and major royal jelly proteins were enriched at the T2 stage; small heat shock proteins showed significantly higher expression at the T3 stage; and some metabolism-related genes were more highly expressed at the T4 stage. The DEGs identified in this study may serve as a valuable resource for the characterization of expression patterns of antennal genes in A. cerana cerana. Furthermore, this study provides insights into the relationship between labor division in social bees and gene function.

Soft tissue calcifications secondary to Hymenoptera stings: a potential prognostic CT imaging sign in pediatric patients

CONTEXT

Soft tissue calcifications (STCs) were incidentally found in some of the Hymenoptera-stung (HS) children when they underwent computed tomography (CT) scans for evaluating complications of vital organs. Afterwards, a predilection of STCs to the children with severe complications was clinically noticed. A hypothesis was then developed that STCs secondary to HS may correlate with poor outcomes.

OBJECTIVE

This study aims to firstly characterize the CT findings of STCs in HS children and to confirm our hypothesis that the occurrence of STCs may act as an indicator of poor outcomes in HS children.

MATERIALS AND METHODS

Children who received CT scanning after Hymenoptera sting from January 2011 to October 2016 in our hospital were analyzed retrospectively. Shape, location, and distribution of the STCs were described according to the CT findings. Then the enrolled cases were classified into Soft Tissue Calcification Group (STCG) and non-Soft tissue Calcification Group (non-STCG) to conduct prognostic comparisons of Sequential Organ Failure Assessment (SOFA) scores, incidence of main complications (acute liver failure (ALF), acute kidney injury stage III (AKI-III) and multiple organ failure (MOF)), length of hospital days, and in-hospital death, respectively. Pearson correlation was also utilized between the cumulative volume of STCs and the SOFA score.

RESULTS

Sixteen cases were enrolled, and STCs' incidence was 56.25% (9/16). Two STCG cases had diffuse nodular calcifications in their swollen subcutaneous tissue, and another seven had symmetrically stripy or patchy calcifications within or along local muscles. The SOFA scores during the first 3 days were all higher in STCG, and rose to the greatest difference at the third day (9.78 ± 2.17 vs. 2.29 ± 2.06, t = 7.009, p < .001); the incidence of ALF, AKI-III and MOF were significantly higher in STCG (66.67% vs. 0, p = .011), (77.78% vs. 0, p = .003) and (77.78% vs. 14.29%, p = .041); and children in STCG were treated with longer hospital durations (26.33 ± 8.41 days vs. 12.29 ± 7.36 days, t = 3.493, p = .004). One child in STCG died of cardiopulmonary failure, and no deaths occurred in non-STCG. No significant correlations presented between STCs cumulative volumes and SOFA score (r_Day1 = 0.096, p = .806; r_Day2 = 0.067, p = .863; r_Day3 = 0.024, p = .950).

CONCLUSION

Soft tissue calcifications detected on CT imaging following multiple Hymenoptera stings in pediatric patients may be a potential prognostic indicator of more severe complications and poorer outcomes.

Envenomation Seizures

Insect sting-related envenomation rarely produces seizures. We present a patient with confusion and seizures that began 24 hours after a yellow jacket (wasp) sting. Given the rapid onset and resolution of symptoms, as well as accompanying dermatological and orbital features, and the lack of any infectious or structural abnormalities identified, the toxic effect of the wasp venom (and related anaphylaxis reaction) was believed to be the cause of his presentation.

A honey bee can threat ear: Sudden sensorineural hearing loss

Sudden sensorineural hearing loss is an otologic emergency. Many etiological factors can lead to this pathology. Honey bee (Apis mellifera) sting may lead to local and systemic reactions due to sensitization of the patient. In this paper we described a sudden sensorineural hearing loss occurred after honey bee sting.

Acute kidney injury complicating bee stings - a review

Bee stings can cause severe reactions and have caused many victims in the last years. Allergic reactions can be triggered by a single sting and the greater the number of stings, the worse the prognosis. The poisoning effects can be systemic and can eventually cause death. The poison components are melitin, apamin, peptide 401, phospholipase A2, hyaluronidase, histamine, dopamine, and norepinephrine, with melitin being the main lethal component. Acute kidney injury (AKI) can be observed in patients suffering from bee stings and this is due to multiple factors, such as intravascular hemolysis, rhabdomyolysis, hypotension and direct toxicity of the venom components to the renal tubules. Arterial hypotension plays an important role in this type of AKI, leading to ischemic renal lesion. The most commonly identified biopsy finding in these cases is acute tubular necrosis, which can occur due to both, ischemic injury and the nephrotoxicity of venom components. Hemolysis and rhabdomyolysis reported in many cases in the literature, were demonstrated by elevated serum levels of indirect bilirubin and creatine kinase. The severity of AKI seems to be associated with the number of stings, since creatinine levels were higher, in most cases, when there were more than 1,000 stings. The aim of this study is to present an updated review of AKI associated with bee stings, including the currently advised clinical approach.

Wasp venomic: Unravelling the toxins arsenal of Polybia paulista venom and its potential pharmaceutical applications

Polybia paulista (Hymenoptera: Vespidae) is a neotropical social wasp from southeast Brazil. As most social Hymenoptera, venom from P. paulista comprises a complex mixture of bioactive toxins ranging from low molecular weight compounds to peptides and proteins. Several efforts have been made to elucidate the molecular composition of the P. paulista venom. Data derived from proteomic, peptidomic and allergomic analyses has enhanced our understanding of the whole envenoming process caused by the insect sting. The combined use of bioinformatics, -omics- and molecular biology tools have allowed the identification, characterization, in vitro synthesis and recombinant expression of several wasp venom toxins. Some of these P. paulista - derived bioactive compounds have been evaluated for the rational design of antivenoms and the improvement of allergy specific diagnosis and immunotherapy. Molecular characterization of crude venom extract has enabled the description and isolation of novel toxins with potential biotechnological applications. Here, we review the different approaches that have been used to unravel the venom composition of P. paulista. We also describe the main groups of P. paulista - venom toxins currently identified and analyze their potential in the development of component-resolved diagnosis of allergy, and in the rational design of antivenoms and novel bioactive drugs.

Henoch Schonlein purpura associated with bee sting: case report

Henoch Schonlein purpura (HSP) is a common childhood vasculitis, characterized by a non-thrombocytopenic palpable purpura and systemic features. It can be triggered by conditions like infections and insect bites. We present the case of a six-year-old girl with palpable maculopapular lesions on the lower limbs, itching, mild pain, swelling of feet, limitation of limb mobility, and a history of bee sting. Thigh skin biopsy was performed, with a report of leucocytoclastic vasculitis, and was diagnosed as HSP. She was prescribed bed rest, and was given oral hydration. The patient outcome was favorable and was discharged after five days. This is the fifth report of a HSP case associated with a bee sting with an uncomplicated course, which is in contrast to previous case reports.

Why do we study animal toxins?

Venom (toxins) is an important trait evolved along the evolutionary tree of animals. Our knowledges on venoms, such as their origins and loss, the biological relevance and the coevolutionary patterns with other organisms are greatly helpful in understanding many fundamental biological questions, i.e., the environmental adaptation and survival competition, the evolution shaped development and balance of venoms, and the sophisticated correlations among venom, immunity, body power, intelligence, their genetic basis, inherent association, as well as the cost-benefit and trade-offs of biological economy. Lethal animal envenomation can be found worldwide. However, from foe to friend, toxin studies have led lots of important discoveries and exciting avenues in deciphering and fighting human diseases, including the works awarded the Nobel Prize and lots of key clinic therapeutics. According to our survey, so far, only less than 0.1% of the toxins of the venomous animals in China have been explored. We emphasize on the similarities shared by venom and immune systems, as well as the studies of toxin knowledge-based physiological toxin-like proteins/peptides (TLPs). We propose the natural pairing hypothesis. Evolution links toxins with humans. Our mission is to find out the right natural pairings and interactions of our body elements with toxins, and with endogenous toxin-like molecules. Although, in nature, toxins may endanger human lives, but from a philosophical point of view, knowing them well is an effective way to better understand ourselves. So, this is why we study toxins.

Facing Hymenoptera Venom Allergy: From Natural to Recombinant Allergens

Along with food and drug allergic reactions, a Hymenoptera insect Sting (Apoidea, Vespidae, Formicidae) is one of the most common causes of anaphylaxis worldwide. Diagnoses of Hymenoptera venom allergy (HVA) and specific immunotherapy (SIT) have been based on the use of crude venom extracts. However, the incidence of cross-reactivity and low levels of sensibility during diagnosis, as well as the occurrence of nonspecific sensitization and undesired side effects during SIT, encourage the search for novel allergenic materials. Recombinant allergens are an interesting approach to improve allergy diagnosis and SIT because they circumvent major problems associated with the use of crude venom. Production of recombinant allergens depends on the profound molecular characterization of the natural counterpart by combining some “omics” approaches with high-throughput screening techniques and the selection of an appropriate system for heterologous expression. To date, several clinically relevant allergens and novel venom toxins have been identified, cloned and characterized, enabling a better understanding of the whole allergenic and envenoming processes. Here, we review recent findings on identification, molecular characterization and recombinant expression of Hymenoptera venom allergens and on the evaluation of these heterologous proteins as valuable tools for tackling remaining pitfalls on HVA diagnosis and immunotherapy.