Massive honey bee envenomation-induced rhabdomyolysis in an adolescent

Fatal Africanized bee attack in captive non-human primates (Saimiri ustus and Sapajus libidinosus)

Bee stings (BS) are a life-threatening issue and a growing concern for public health and animals in the Americas. We describe the clinical, pathological, and ultrastructural findings of a massive lethal bee attack in two non-human primates (NHPs). Both animals showed BS scattered throughout the skin, surrounded by a local reaction, diffuse pulmonary congestion, edema, hemorrhage, and remarkable degeneration and necrosis of renal epithelial cells from the proximal and distal tubules, characterizing a systemic bee envenomation reaction.

Fatal outcome following multiple bee stings: A rare case

Anaphylactic shock is an unexpected, life-threatening, and sometimes fatal occurrence that affects patients in 75% of instances without a prior history of allergies. The severity of the reaction can vary among individuals. We report a case who died suddenly after being stung by bees in various parts of his body.

Insect Body Defence Reactions against Bee Venom: Do Adipokinetic Hormones Play a Role?

Bees originally developed their stinging apparatus and venom against members of their own species from other hives or against predatory insects. Nevertheless, the biological and biochemical response of arthropods to bee venom is not well studied. Thus, in this study, the physiological responses of a model insect species (American cockroach, Periplaneta americana) to honeybee venom were investigated. Bee venom toxins elicited severe stress (LD₅₀ = 1.063 uL venom) resulting in a significant increase in adipokinetic hormones (AKHs) in the cockroach central nervous system and haemolymph. Venom treatment induced a large destruction of muscle cell ultrastructure, especially myofibrils and sarcomeres. Interestingly, co-application of venom with cockroach Peram-CAH-II AKH eliminated this effect. Envenomation modulated the levels of carbohydrates, lipids, and proteins in the haemolymph and the activity of digestive amylases, lipases, and proteases in the midgut. Bee venom significantly reduced vitellogenin levels in females. Dopamine and glutathione (GSH and GSSG) insignificantly increased after venom treatment. However, dopamine levels significantly increased after Peram-CAH-II application and after co-application with bee venom, while GSH and GSSG levels immediately increased after co-application. The results suggest a general reaction of the cockroach body to bee venom and at least a partial involvement of AKHs.

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.

Case Report: Acute Kidney Failure due to Massive Envenomation of a Two-Year-Old Child Caused by Killer Bee Stings

A hybrid species of Brazilian bee has proliferated on the South American continent since 1956. We describe a “killer bee” swarm attack on a 2-year-old girl in French Guiana. The patient weighed 10 kg, and approximately hundreds of bees’ stingers were removed, that is, 10 stings/kg. Our patient survived without long-term sequelae. The management of her condition required admission into intensive care for renal failure due to acute tubular necrosis and severe rhabdomyolysis. We emphasize the importance of early medical intervention, clinical surveillance, and biological monitoring at the hospital to prevent a toxic chain reaction that could prove fatal within 72 hours.

Rhabdomyolysis in Children: Three Exotic Presentations from Suriname

We describe three clinical cases of Surinamese children with rhabdomyolysis with diverse clinical presentation and course. The first patient had rhabdomyolysis because of toxins caused by multiple beestings and developed acute kidney injury. The other two patients had rhabdomyolysis following acute infection with chikungunya and influenza A/H1N1 virus. These cases emphasize that the diverse etiology of rhabdomyolysis should be considered in children in tropical settings.

A Fatal Case of Acute Renal Failure From Envenoming Syndrome After Massive Bee Attack: A Case Report and Literature Review

Envenoming syndrome is a systemic toxic reaction to the inoculation of large volume of insect venom, typically after a swarm attack from bees. Africanized honey bees are notorious for their aggressive nature, and human deaths resulting from Africanized honey bee attacks are consistently reported. Whereas anaphylaxis is the most common lethal mechanism of injury, delayed deaths can also occur as a consequence of severe venom toxicity with resultant end organ damage. Acute renal failure complicating massive envenomation is a rare but potentially fatal outcome after Africanized honey bee attack and may be heralded by laboratory evidence of rhabdomyolysis.

Clinical consequences of toxic envenomations by Hymenoptera

Many familiar Hymenoptera are brightly colored and can sting painfully-thus, their threat and clinical importance may be exaggerated. Most stinging insects only sting to defend themselves or their colonies from predators. The clinical nature of Hymenoptera envenomations contrasts that of other venomous animals, including other arthropods, primarily because allergic reaction, not direct intoxication, is the usual main concern. This review focuses mainly on the clinical features of direct toxicity to Hymenoptera envenomations, which can induce a high incidence of acute renal failure, liver failure, multiple organ failures, and death. Toxic mass envenomations by honeybees usually entail many hundreds or more stings per victim. In contrast to honeybee toxic envenomations, hornet sting envenomations can be clinically threatening with only 20-200 stings needed to cause kidney and other organ failures. Many lethal envenomations by honeybees occur in rural areas in the New World and Africa and are not recorded or documented. In contrast, deaths by hornets occur mainly to Asia. The most frequent and important envenomating taxa are honeybees, hornets, yellowjacket wasps, paper wasps, fire ants, and jack jumper ants. Occasional envenomating taxa include bumblebees, bullet ants, harvester ants, solitary wasps, solitary bees, and various ants of lesser clinical importance. Envenomations by Hymenoptera usually can be avoided if one considers that bees, wasps and ants "view" us as potential threats or predators, and that with information about the biology of stinging Hymenoptera, humans can minimize adverse incidents.

Rhabdomyolysis with different etiologies in childhood

AIM

To investigate different etiologies and management of the rhabdomyolysis in children.

METHODS

Eight pediatric rhabdomyolysis cases who applied to the Dokuz Eylul University Faculty of Medicine Department of Pediatric Nephrology with different etiologies between January 2004 and January 2012 were evaluated in terms of age, gender, admission symptoms, physical examination findings, factors provoking rhabdomyolysis, number of rhabdomyolysis attacks, laboratory results, family history and the final diagnosis received after the treatment.

RESULTS

Average diagnosis ages of eight cases were 129 (24-192) ± 75.5 mo and five of them were girls. All of them had applied with the complaint of muscle pain, calf pain, and dark color urination. Infection (pneumonia) and excessive physical activity were the most important provocative factors and excessive licorice consumption was observed in one case. In 5 cases, acute kidney injury was determined and two cases needed hemodialysis. As a result of the further examinations; the cases had received diagnoses of rhabdomyolysis associated with mycoplasma pneumoniae, sepsis associated rhabdomyolysis, licorice-induced hypokalemic rhabdomyolysis, carnitine palmitoyltransferase II deficiency, very long-chain acyl-CoA dehydrogenase deficiency, congenital muscular dystrophy and idiopathic paroxysmal rhabdomyolysis (Meyer-Betz syndrome).

CONCLUSION

It is important to distinguish the sporadic and recurrent rhabdomyolysis cases from each other. Recurrent rhabdomyolysis cases should follow up more regardful and attentive.

An accidental fatal attack on domestic pigeons by honey bees in Bangladesh

Fatalities among avian species due to multiple bee stings are rare. Sixteen pigeons on a farm in Bangladesh each suffered multiple bee stings. Ten of the pigeons died before treatment, 5 (4–11 stings) died within 12 hr after treatment, and 1 pigeon (only 3 stings) survived. Body temperature, heart rate, respiratory rate, hematocrit, hemoglobin, erythrocytes, thrombocytes, MCV, MCH and MCHC decreased significantly after the incident, but leucocytes, heterophils, basophils, eosinophils, monocytes, ALT, AST, LDH, CK, creatinine, BUN and UA increased markedly. Overall, the hematological and biochemical changes in the bee-stung pigeons were similar to those of mammals; however, avian species may be more sensitive to bee stings than mammals.

Nephritic syndrome following multiple bee stings: a late hypersensitivity reaction

Most hypersensitivity reactions to insect stings are immediate, ranging from transient local reactions of little medical consequence to fatal anaphylaxis. Rarely, some patients have delayed reactions after a period of apparent normality which manifest as systemic features which can be life-threatening. A 3-year-old boy was attacked by a swarm of bees, estimated to be about 200 in number. There was an immediate cutaneous reaction which was treated at a local hospital. After 9 days, he presented with oliguria, dark-coloured urine, pedal oedema, hypertension and acute kidney injury (AKI). He was managed conservatively with fluid restriction, control of blood pressure and peritoneal dialysis, and renal function returned to normal gradually over the following 9 days. The delayed-onset AKI and other laboratory abnormalities suggested a immune-mediated type III hypersensitivity reaction leading to renal insufficiency. After improvement of initial hypersensitivity reactions, patients with bee stings should be followed up in order to detect any late-onset complications which might be life-threatening.

RRH: envenoming syndrome due to 200 stings from Africanized honeybees

Envenoming syndrome from Africanized bee stings is a toxic syndrome caused by the inoculation of large amounts of venom from multiple bee stings, generally more than five hundred. The incidence of severe toxicity from Africanized bee stings is rare but deadly. This report reveals that because of the small volume of distribution, having fewer stings does not exempt a patient from experiencing an unfavorable outcome, particularly in children, elderly people or underweight people.

Africanized honeybee stings: how to treat them

INTRODUCTION

In 1956, Africanized honeybees (AHB) migrated from Brazil to other regions of the Western Hemisphere, including South, Central, and North America, except for Canada. Despite being productive, they are highly aggressive and cause fatal accidents. This study aimed to evaluate patients at the Clinical Hospital of Botucatu Medical School (HC-FMB) and to propose treatment guidelines.

METHODS

From 2005 to 2006, the clinical and laboratorial aspects of 11 patients (7 male and 4 female) and the anatomopathological aspects of one patient who had died in 2003 were analyzed.

RESULTS

The age of the surviving patients varied from 5 to 87 years, with a mean of 42.5 years. The majority of accidents occurred in the afternoon, and the number of stings ranged from 20 to 500. The principal signs and symptoms were pain and local inflammatory signs, nausea, tachycardia, and vomiting. Biochemical findings presented increased levels of creatine phosphokinase, lactate dehydrogenase, and aspartate/alanine aminotransferase. An 11-year-old male patient died upon entering the attic of a two-story building where he was attacked by a swarm, receiving more than 1,000 stings. He was sent to HC-FMB where he was treated, but he died 24h later. Observed at the autopsy were erythematous-purpuric skin lesions besides necrosis at the sting locations, rhabdomyolysis, focal myocardial necrosis, tubular hydropic degeneration and focal tubular acute necrosis of the kidneys, myoglobinuria, and centrolobular necrosis in the liver.

CONCLUSIONS

Accidents caused by multiple AHB stings always constitute a medical emergency. As there is no specific antivenom, we have developed guidelines, including first aid, drugs, and the proper removal of stingers.

Bee (Apis mellifera) venom produced toxic effects of higher amplitude in rat thoracic aorta than in skeletal muscle--an ultrastructural study

In this study, changes produced in aorta and triceps surae muscle of Wistar rats as response to bee venom (BV) envenomation were analyzed by transmission electron microscopy and morphometry. A subchronic treatment of 30 days with daily doses of 700 μg BV/kg and an acute-lethal treatment with a single dose of 62 mg BV/kg were performed. The subchronic treatment resulted in endothelial cell retraction, a thicker subendothelial layer, and thinner elastic laminae and musculoelastic layers in aorta, and thicker endothelium and basal laminae in skeletal muscle. In both tissues polymorphous, swollen mitochondria with disrupted cristae were observed. The acute treatment produced extensive endothelial lesions, breakdown of the collagen layer and migration of muscle cells toward the intima in the aorta, and dilatation of endoplasmic reticulum in the skeletal muscle cells. Mitochondria were almost devoid of cristae or with few circular cristae in the smooth muscle cells while most of the mitochondria presented abnormal circular cristae in the skeletal muscle cells. Degenerative alterations in the aorta were of higher intensity in our experiments-both the intima and media strongly responded to BV, in contrast to those found at the level of the skeletal muscle cells where a moderate degenerative myopathy was recorded.

Historical perspective and human consequences of Africanized bee stings in the Americas

In 1956, Africanized bees began to spread in the American continent from southern Brazil, where original African bees mated with European bees. A few years later, in 1990, these Africanized bees reached the United States and were found in Texas. Currently, these hybrid bees are found in several North American states and will probably reach the Canadian border in the future. Although the presence of Africanized bees had produced positive effects on Brazilian economy, including improvement in crop pollination and in honey production, turning Brazil into a major exporter, the negative impacts-such as swarming, aggressive behavior, and the ability to mass attack-resulted in serious and fatal envenomation with humans and animals. Victims of bee attacks usually develop a severe envenomation syndrome characterized by the release of a large amount of cytokines [interleukins (IL) IL-1, IL-6, IL-8], and tumor necrosis factor (TNF). Subsequently, such cytokines produce an acute inflammatory response that triggers adverse effects on skeletal muscles; bone marrow; hepatic and renal functions; and cardiovascular, central nervous, and immune systems. Finally, the aim of the present review is to study historical characteristics and current status of Africanized bees' spread, the composition of their venom, the impact of the bees on the Brazilian economy and ecology, and clinical aspects of their stings including immune response, and to suggest a protocol for bee sting management since there is no safe and effective antivenom available.

Multiorgan failure following mass wasp stings

Wasp bites usually bring temporary discomfort and pain, but on occasion, they can cause serious infections and fatal allergic reactions. We report on a patient who experienced massive wasp stings and developed multiple organ failure, including acute kidney, hepatic failure, and circulatory collapse 4 days later. He was treated with aggressive fluid resuscitation, inotropic agent, intravenous injection of steroids, broad-spectrum antibiotics, and hemodialysis. After intensive treatment, his liver function recovered one month later. Recovery of renal function was delayed, and the patient needed temporary regular hemodialysis. The pathology of kidney biopsy showed acute tubulointerstitial nephritis. This case shows that toxic reactions following massive wasp attacks may happen several days after the fact and result in severe, multiorgan system dysfunction.

Massive hymenoptera envenomation in a 3-year-old

BACKGROUND

Envenomation by a large number of hymenopterans can cause significant morbidity and mortality due to venom load. We present the first case of massive Hymenoptera envenomation by native US Hymenoptera.

CASE

A 3-year-old boy and his family were hiking in Oregon and were attacked by yellow jackets. On emergency department arrival, the child was uncomfortable and vomiting. Vital signs were normal; physical examination showed more than 90 punctate lesions on the head and neck, and 30 below the neck without urticaria. Initial laboratory values were normal except for a white blood cell count of 37,500/μL and mild hypokalemia, including a normal creatinine kinase. Intravenously administered fluids, ondansetron, midazolam, and morphine were given for symptom control.Generalized edema developed 12 hours later and was treated with intravenously administered dexamethasone and diphenhydramine. His creatinine kinase peaked at 2085 U/L after 32 hours. Forty-eight hours after the incident, the child began to take oral fluids with laboratory values returning to normal.

DISCUSSION

Delayed toxic effects of mass envenomation are due to direct toxic effects from the large venom load, with several cases of death reported. All prior cases of mass Hymenoptera envenomation in the United States have involved Africanized "killer" honeybees. Guidelines recommend admitting all pediatric patients sustaining more than 50 stings for 24 hours for laboratory evaluations.

CONCLUSIONS

Delayed toxic reaction may be caused by native US species of Hymenoptera. Physicians should be aware that endemic US species can cause this reaction and should have a low threshold to admit pediatric patients with more than 50 stings for 24 hours.

Multiple hymenoptera stings in children: clinical and laboratory manifestations

Multiple hymenoptera stings are a cause of rhabdomyolysis, elevated liver enzymes, clotting abnormalities, kidney injury, and even death. However, the progression of the clinical and laboratory findings has been described mainly in sporadic case reports. We report the clinical and laboratory manifestations of multiple hymenoptera stings in six children who were hospitalized and referred for a nephrology evaluation and follow-up over a 12-year period. One patient succumbed 13 h after the stinging accident. In the five surviving patients, we found somewhat similar pattern of clinical and laboratory course: rhabdomyolysis with elevated liver enzymes are the earliest manifestations, followed by kidney injury and anemia. An asymptomatic phase of several days between the stinging accident and severe kidney injury can occur. There was a strong seasonal association, with all six events occurring in August or September. In children with multiple hymenoptera stings, a somewhat predictable clinical and laboratory course is expected and an initial laboratory evaluation is needed, and even in asymptomatic children, a repeated laboratory evaluation is highly recommended.

Acute physiopathological effects of honeybee (Apis mellifera) envenoming by subcutaneous route in a mouse model

Bee stings are a health concern in the Americas, where fatal envenomings due to massive attacks by Africanized honeybees have been documented in the last decades. Most studies on the toxic effects of honeybee venom in experimental animals have been performed using the intravenous or intraperitoneal injection routes. The aim of this study was to develop a mouse model that would better resemble a massive honeybee attack by using the subcutaneous (s.c.) route to induce a severe, sublethal systemic envenoming. An array of acute venom effects were characterized, including biochemical, hematological, histological, and inflammatory alterations, after the s.c. injection of 0.5 median lethal dose of venom. Rapid increases in serum alanine (ALT) and aspartate (AST) transaminases, creatinine, urea nitrogen, uric acid, sodium and chloride electrolytes, and creatine kinase (CK) were recorded, indicating damage to liver, kidneys, and skeletal muscle. Also, coagulation disturbances (fibrinogen decrease, and moderate delay in prothrombin and partial thromboplastin times) were demonstrated. Circulating platelet and leukocyte numbers remained unaltered, but a hemoconcentration effect (hematocrit and hemoglobin increase) was observed. This effect might be related to the marked edema induced by the venom. In addition, this inflammatory response included a systemic increase in cytokines (IL-1 beta, IL-6, TNF-alpha), together with an elevation of serum malondialdehyde and nitric oxide. The myotoxic effects of venom, melittin, and phospholipase A(2) were demonstrated after injection by s.c. route. No synergistic myotoxicity between melittin and PLA(2) was observed. Moreover, these two components, when injected at equivalent concentrations to those present in venom, induced a lower increase in serum CK than venom, suggesting that other components also contribute to its strong systemic toxicity towards skeletal muscle. The model here presented may be useful in preclinical studies to assess therapeutic antivenoms developed to cope with the problem of massive bee attacks.

A Rare Case of Severe Intoxication from Multiple Bee Stings with a Favorable Outcome

A 73-year old female of no allergic diathesis was attacked by bees and stung all over her body accidentally sustaining more than 518 stings for a very short time. Severe acute poisoning developed from the bee venom, manifested by coma, rhabdomyolysis, toxic hepatitis, acute renal failure, gastric hemorrhage and anemia. Following an active treatment the patient recovered. Literature search shows this to be a rare case of survival after multiple bee stings.

Reducing honey bee defensive responses and social wasp colonization with methyl anthranilate

Human victims of a massive number of stings have been steadily increasing since the invasion of Africanized honey bees (Apis mellifera) to the United States in 1990. Multiple honey bee stings may result in venom toxicity, leading to renal failure and even death. Here we tested the efficacy of methyl anthranilate as a honey bee repellent during a massive defensive response by Africanized honey bees. An aerosolized solution of 10% methyl anthranilate reduced the number of defensive bee hits to a retreating victim by 95% compared with a water control. One hundred fifty milliliters of the 10% methyl anthranilate solution sprayed onto stationary foam balls covered with black suede leather located 2 m from provoked Africanized colonies received 80% fewer stings than targets treated with water. Methyl anthranilate (100%) delivered through a UV blocking 3 mil polyethylene pouch was 100% effective in preventing Polistes colonization in wildlife observation huts and from the roof overhang of home patios. Although methyl anthranilate was not 100% effective in preventing honey bee stinging, it seemed to reduce number of stings below the average human LD50, indicative of a promising tool for preventing honey bee venom toxicity and wasp colonization.

Rhabdomyolysis: a review of clinical presentation, etiology, diagnosis, and management

Rhabdomyolysis is a condition that results from many underlying etiologies and can present in a myriad of ways to the emergency physician. However, some clinical and laboratory features are almost always present and, if noted, can help in making the diagnosis. This review article will focus on the presenting symptoms, the various etiologies, the underlying mechanisms, and the current management of pediatric rhabdomyolysis.

Bee swarmings in children

Africanized honeybees (Apis mellifera scutellata) are now found in the southern and southwestern United States. Swarmings can result in hundreds to thousands of stings delivering a venom load capable of producing multisystem organ failure and death. The literature on mass envenomations is scarce, being limited to case reports and case series. There are no prospective studies on mass envenomations in children.

METHODS

All patients were admitted to our toxicology service, and all stingers were counted. Laboratory data and clinical assessments were obtained at baseline, 8, and 16 hours after presentation.

RESULTS

Nineteen patients with a median age of 3.6 years and a median of 2.64 stings per kilogram (range, 1-4.5) were enrolled. Fifteen children had vomiting. Only a mild increase in creatine kinase was seen. None developed coagulopathy or renal insufficiency.

CONCLUSION

Envenomations of up to 4.5 stings per kilogram resulted in only mild systemic illness. Vomiting does not portend involvement of other organ systems.

Pathological findings in dogs after multiple Africanized bee stings

This retrospective study included 19 dogs that died by intoxication due to multiple Africanized bee stings. Bee accidents occurred in rural and urban areas of the Rio Grande do Sul state, southern Brazil. Although bee stings were associated with edema and hyperemia in several regions of the body, head and neck were the most commonly and massively affected areas. Stingers and bees were also observed in the digestive tract. Dark-colored kidneys, dark-red urine, splenomegaly, and dark red lungs were the main gross changes. Histologically, all the dogs had kidney tubular degeneration and necrosis, which were associated with tubular pigment accumulation in most cases. Other lesions included muscular necrosis, hemorrhage in different organs, marked congestion of the spleen and pulmonary edema and congestion.