Multiple hornet stings with features of Reye's syndrome

Clinical manifestations of wasp stings: a case report and a review of literature

Background

Wasp stinging, a neglected tropical entity can have a myriad of local and systemic effects. We present a case of multi-organ injury following multiple wasp stings and a review of literature on the systemic manifestations of wasp stings.

Case presentation

A 48-year-old Sri Lankan male who suffered multiple wasp stings, developed an anaphylactic shock with respiratory failure, which was treated with adrenaline and mechanical ventilation. Within the next 2 days the patient developed acute fulminant hepatitis, stage III acute kidney injury, rhabdomyolysis, haemolysis and thrombocytopenia. The patient was treated in the intensive care unit with ionopressors and continuous renal replacement therapy (CRRT). Haemoadsorbant therapy was used in adjunct with CRRT. There was a gradual recovery of the organ functions over the 1st week. However, the patient succumbed to fungal sepsis on the 16th day despite treatment. We conducted a literature review to identify the various clinical manifestations of wasp stinging. Wasp venom contains enzymes, amines, peptides and other compounds. These proteins can cause type 1 hypersensitive reactions ranging from local skin irritation to anaphylactic shock. Furthermore, the toxins can cause direct organ injury or delayed hypersensitivity reactions. The commonly affected organs are the kidneys, liver, and muscles. The effect on the haematological system manifests as coagulopathy and/or cytopenia. The heart, nervous system, lungs, intestines and skin can be affected rarely. Treatment is mainly supportive.

Conclusion

In conclusion, wasp envenomation can result in multi-organ injury and attention should be paid in doing further research and establishing evidence-based treatment practices.

Acute renal failure following wasp sting in children

The medical records of patients admitted between 1985 and 2007 with wasp stings were retrospectively analyzed. Among the 45 children, seven developed acute renal failure. Classical clinical and laboratory data pointed to hemolysis and rhabdomyolysis as the underlying pathophysiology. All patients had hyponatremia and hyperkalemia as well as metabolic acidosis. Six patients had anemia. Five patients were oliguric for 9 to 15 days. Maximum serum creatinine was 4.0 to 11.9 mg/dl. Peritoneal dialysis was performed for 3 to 15 days. One patient died due to hyperkalemia, the remaining ones recovered completely. This paper wants to remind pediatricians to watch for acute renal failure in children with wasp stings.

Acute tubulointerstitial nephritis after wasp stings

A 61-year-old Caucasian man presented with acute renal failure after multiple wasp stings. The patient required dialysis support temporarily. Work-up failed to show rhabdomyolysis or hemolysis and a kidney biopsy revealed acute allergic interstitial nephritis. The patient's renal function recovered completely after a short course of steroid therapy. Acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of hemolysis or rhabdomyolysis. Compared with previously reported cases of acute renal failure associated with bee stings, our patient is unique in that his renal failure was caused by a hypersensitivity reaction apparently to the wasp venom.

Fatal multiple organ failure following massive hornet stings

We describe a fatal outcome in a three-year-old child following massive stings by the oriental hornet (Vespa orientalis). The primary clinical features were coma, respiratory failure, coagulopathy, renal failure and liver dysfunction. On postmortem the main organs involved were brain, lungs, kidney and liver.

Hepatotoxicity induced by the Oriental hornet (Vespa orientalis) venom sac extract

Experiments were performed to investigate the nature of the in vitro and human liver damage exposed to hornets' acute or repeated stings. The hornet investigated is the one ubiquitous in Israel - Vespa orientalis. Experiments were performed in living cats and rats, after single or multiple exposures to venom-sac extracts (VSE) and in various doses. The injury was demonstrated by the increased levels of enzymes, bile acids and cholesterol in serum. Also measured was Beta-N-acetyl hexosaminidase (BNAH) which probably is the only biochemical indicator available of Kupffer-cell function. This, too, was found increased. Other experiments consisted of perfusion of the isolated, intact, rat liver in situ with measurements of enzyme leakage into perfusate and of bile flow. Another set of experiments involved the effects of VSE on in vitro monolayer tissue culture of rat embryos' livers. We examined damage to organelles and compared the damage produced by intact VSE with that produced by the venom sac extract after treatment by heat or dialysis. Light morphology, special stains, electron microscopy and morphometry were all performed. In the first set of experiments no shock was observed in cats and rats exposed to VSE. The increases in enzymes' activity in serum and liver perfusion fluid were significant. Histochemistry indicated decrease of hepatic glycogen and of cellular succinic dehydrogenase as well as hepatic fat infiltration and an increase of alkaline phosphatase activity in liver cells close to the bile capillaries.(ABSTRACT TRUNCATED AT 250 WORDS)

Interrelationships of liver and brain with special reference to Reye syndrome

Reye syndrome is an acute non-inflammatory encephalopathy that can be precipitated by toxic, infective, metabolic or hypoxic upsets. The biochemical changes point to mitochondrial dysfunction and this is substantiated by structural changes in mitochondria on electron microscopy. The toxic metabolites that accumulate are similar to those incriminated in hepatic encephalopathy and other metabolic diseases. These metabolites exert their deleterious effects by direct neuronal damage, neurotransmitter blockade, vascular damage, cerebral oedema, hypoxic ischaemic damage, demyelination, retardation of brain growth and neuronal storage. Brain capillary endothelial cells are very rich in mitochondria and mitochondrial disorders can effect the central nervous system primarily, and not just as a consequence of systemic metabolic upset.

Multiple hornet (Vespa orientalis) stings with fatal outcome in a child

A case of multiple hornet stings is described with a rapidly fatal course due to the combination of massive haemolysis, coagulopathy, rhabdomyolysis, hyperkalaemia, acute renal failure, encephalopathy, hepatotoxicity and hyperglycaemia. These features of systemic envenomation can all be attributed to the toxic properties of Oriental hornet venom described in in vitro and in vivo experimental studies. Greater awareness of these features, aggressive treatment of hyperkalaemia and early institution of treatments such as peritoneal dialysis and plasma exchange may prevent fatalities in such cases.

Cortical cerebral blood flow is enhanced by hornet venom

This study examined the effect of Oriental hornet venom sac extract (VSE) on the rate of local blood flow in the cerebral cortex of rats. Sublethal doses of VSE in isotonic saline solution were injected into the femoral vein of anaesthetised rats and the rate of blood flow was assessed by the hydrogen clearance technique both before the envenomation as well as during the following 150 min. The injection of VSE was found to induce a prolonged elevation of blood flow in the cerebral cortex. The time of occurrence of this elevation varied in different rats and so also the intensity of the elevation, ranging between 47-212% of the basal values. No exceptional or toxic phenomena were recorded in the course of this investigation. It would seem that the factor(s) responsible for boosting the blood flow is probably one or more of the water soluble components of the hornet venom.

Hepatotoxic effects of repeated administration of oriental hornet (Vespa orientalis) venom

Venom sac extract (VSE) of the Oriental hornet (Vespa orientalis) has been shown to exert a toxic effect on hepatic cells. The present work set out to examine its effect on liver cells using serum levels of a lysosomal hydrolase as a marker of injury in rats. Serum activities of beta-N-acetyl hexosaminidase (BNAH; EC 3.2.1.30) were found to be positively correlated with the number of treatments received by the rats. The maximal elevation occurred from the third to the sixth day and comprised a 2-3-fold increase over the control mean level. This enhancement effect was reversible. The rat envenomend for 2 wk showed 3.5 times as much BNAH activity as in control rats. Biochemical analysis revealed increased specific activity of the lysosomal enzyme in rats treated repeatedly with VSE.

Reye's syndrome: current concepts

Despite greater than 23 years of study, an incomplete understanding of the etiology, epidemiology and pathogenesis of Reye's syndrome persists. Better understanding of the disease has been hampered by the lack of a good animal model on which hypotheses of its pathogenesis could be tested. Human studies indicate that a primary mitochondrial injury may lead to complex metabolic disturbances that produce the observed pathophysiology. Specific directions regarding avenues for future research should pursue two lines: a good animal model still needs to be developed in which the biochemical and morphologic alterations identified in Reye's syndrome are duplicated. This model should include an antecedent viral illness but may not require aspirin exposure as an essential ingredient. With the identification of a satisfactory model, specific questions about the roles of environmental toxins or medications may be answered. Study of noncomatose cases of Reye's syndrome should continue. The specific emphasis should be to delineate what factors (NH3, free fatty acids and dicarboxylic acids) may be implicated in the pathogenesis of the CNS disease with the hopes of devising strategies for more effective treatment of encephalopathy and its attendant morbidity and mortality.

Histopathological changes in rat liver following repeated vespine envenomation

The histopathological picture of rat liver was studied after repeated envenomation with hornet (Vespa orientalis) venom sac extract (VSE). Light microscopical and histochemical investigation showed foci of necrosis of the hepatocytes, a decrease in glycogen content and in succinic dehydrogenase activity, some fat infiltration and an increase in alkaline phosphatase activity. Electron microscopy showed a decrease in the number of mitochondria per cell as well as a decrease in their cristae, enlargement of bile canaliculi, and destruction of the endothelium of the sinusoids bringing the cytoplasm of the necrotic hepatocytes in contact with the lumen of the sinusoid. The rat liver is proposed as a model for the study of pathological effects of animal toxins.