Acute renal failure in experimental envenomation with Africanized bee venom

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.

The predictive value of the systemic inflammatory response index for the occurrence of multiple organ dysfunction syndrome in patients with wasp sting injury

Wasp sting injuries pose a significant threat to public health, especially in areas with abundant trees. Mortality rates are alarmingly high, with reports indicating that up to 70% or more of cases result in multiple organ dysfunction syndrome (MODS). It is crucial for emergency and critical care physicians to promptly identify and implement effective measures to reduce the occurrence of MODS in patients who have been stung by wasps. Therefore, finding a reliable predictive indicator is of utmost importance. We conducted a retrospective study, and clinical data of 226 hospitalized patients with wasp sting from July 2013 to April 2023 in the First College of Clinical Medicine Science, China Three Gorges University were collected. The patients were divided into MODS group and non-MODS (NMODS) group, and the general data, clinical symptoms, laboratory indexes, and prognosis were compared between the two groups. The indicators with significant differences in univariate analysis were included in the multivariate Logistic regression analysis to analyze the independent risk factors for MODS. The value of systemic inflammatory response index (SIRI) in predicting the occurrence of MODS in wasp sting was analyzed by using the receiver operating characteristic curve (ROC curve). Of the 214 patients with wasp sting, 109 cases were in the NMODS group, and 105 cases were in the MODS group. The SIRI was 1.6 (0.7, 3.6) and 12.2 (5.2, 23.3) in the NMODS group and MODS group, respectively, with a significant difference between the two groups (P ＜ 0.001). SIRI was an independent risk factor for MODS in patients with wasp sting; the AUC of SIRI in predicting MODS in wasp sting was 0.886 (P ＜ 0.001), and the optimal cutoff value was 6.39, with a sensitivity of 71.43% and a specificity of 94.5%, which had prediction value. Allowing for early identification and enabling doctors to intervene and provide timely treatment. SIRI was defined as follows: SIRI = neutrophil count × monocyte count/lymphocyte count.

Bee Venom Causes Oxidative Stress, Biochemical and Histopathological Changes in the Kidney of Mice

Accidents with venomous bees are a serious worldwide health concern. Since the kidney has been reported as the main venom-target organ, the present study was undertaken to investigate the in vivo nephrotoxic effect of Algerian bee venom (ABV) (Apis mellifera intermissa) collected in the middle east of Algeria. A preliminary study was performed on ABV to identify the ABV using SDS-PAGE analysis and to determine the in vivo intraperitoneal median lethal dose (LD50) using the Probit analysis test. In vivo nephrotoxic effect was assessed through the determination of physiological and kidney biochemical markers in mice intraperitoneally injected with ABV at doses of 0.76 (D1); 1.14 (D2) and 2.29 mg/kg body weight (bwt) (D3), corresponding respectively to LD50/15, LD50/10, and LD50/5 (i.p. LD50=11.48 mg/kg bwt) for seven consecutive days. Results revealed a marked decrease in body weight gain and food intake, and an increase in absolute and relative kidney weights in ABV D2 and D3 treated mice compared with controls. Furthermore, ABV D2 and D3 resulted in a significant increase in serum creatinine, urea, and uric acid. ABV-induced oxidative stress was evidenced by a significant increase in kidney MDA level, and a significant depletion in kidney GSH level, and catalase activity. Meanwhile, no marked changes in the above-mentioned parameters were noticed in ABV D1. Accordingly, the adverse nephrotoxic effect of ABV was proved by the dose-dependent kidney histological changes. In summary, the results of the present study evidence that ABV at doses of 1.14 (D2) and 2.28 mg/kg body weight (bwt) can cause marked changes in kidney biochemical and major antioxidant markers, and histological architecture.

Heparin prevents the cytotoxic activity of Bothrops jararacussu and Apis mellifera venoms in renal cells

Envenomation by Bothrops snakes and Apis mellifera bee may imply systemic disorders which affect well-perfused organs such as kidneys, a process that can lead to acute renal failure. Nevertheless, there is scarce information regarding a direct renal cell effect and the putative antagonism by antivenoms. Here the cytotoxic effect of B. jararacussu and A. mellifera venoms was evaluated in the renal proximal tubule cell line LLC-PK1, as well as the antagonism of this effect by heparin. B. jararacussu venom showed significant cytotoxicity as assessed by LDH release and MTT reduction, with a sharp decline of the cell number after 180 min (>90% at 50 μg/mL). A. mellifera venom produced a much faster and potent cytotoxic activity, conferring almost no viable cells after 15 min at 25 μg/mL. Phase contrast microscopy revealed that while B. jararacussu venom induced a progressive loss of cell adhesion and detachment, A. mellifera venom promoted a rapid plasma membrane disruption and nuclear condensation suggestive of necrotic cell death. Pre-incubation of both venoms with heparin for 30 min significantly reduced cytotoxicity. Our results demonstrate direct toxicity of B. jararacussu and A. mellifera venoms toward renal cells but with distinct kinetics and cell pattern, suggesting different mechanisms of action. In addition, the antagonistic, cytoprotective effect of heparin ascribes such compound as a promising drug for preventing renal failure from envenomation.

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.

Efficacy of Three Renal Replacement Therapy Modalities for the Treatment of Acute Kidney Injury Caused by Wasp Sting

BACKGROUND/AIM

This study mainly aimed to explore the therapeutic effects of 3 renal replacement therapy (RRT) modalities on acute kidney injury (AKI) caused by wasp stings.

METHODS

A retrospective study from September 2016 to December 2019 was conducted. Thirty-one patients with AKIs caused by wasp sting were selected and divided into 3 groups according to the initial RRT modality received, namely, (1) the intermittent hemodialysis combined with hemoperfusion (IHD + HP) group, (2) the continuous veno-venous hemodiafiltration (CVVHDF) group, and (3) the CVVHDF combined with HP (CVVHDF + HP) group. The laboratory results were measured and analyzed before treatment on the 3rd, 7th, and 14th days of treatment. The renal function outcomes and survival of the patients were investigated at 3 months follow-up.

RESULTS

The laboratory results of enzyme measures and inflammatory indicators in wasp sting patients increased significantly in the early stage and 3 RRT modalities were effective in reducing these indicators. In addition, continuous RRT modality (CVVHDF and CVVHDF + HP) showed better clearance of myoglobin than IHD + HP. The serum creatinine levels of patients in the 3 groups did not recover to baseline within 14 days after beginning treatment. Nevertheless, the CVVHDF + HP group was better than the CVVHDF group, and CVVHDF was better than the IHD + HP group on the 3rd day. The interleukin (IL)-6 and IL-10 levels in CVVHDF + HP and IHD + HP groups were obviously lower than those in the CVVHDF group on the 3rd day. In the follow-up study, the recovery rate of renal function in CVVHDF and CVVHDF + HP groups was significantly better than that in the IHD + HP group.

CONCLUSION

Early RRT was effective in the treatment of patients with A KI caused by wasp sting. CVVHDF + HP and CVVHDF modalities were better than the IHD + HP group in venom clearance and renal function recovery.

RS, Barraviera B, Quintas LEM, Melo PA. A Novel Apilic Antivenom to Treat Massive, Africanized Honeybee Attacks: A Preclinical Study from the Lethality to Some Biochemical and Pharmacological Activities Neutralization

Massive, Africanized honeybee attacks have increased in Brazil over the years. Humans and animals present local and systemic effects after envenomation, and there is no specific treatment for this potentially lethal event. This study evaluated the ability of a new Apilic antivenom, which is composed of F(ab’)2 fraction of specific immunoglobulins in heterologous and hyperimmune equine serum, to neutralize A. mellifera venom and melittin, in vitro and in vivo, in mice. Animal experiments were performed in according with local ethics committee license (UFRJ protocol no. DFBCICB072-04/16). Venom dose-dependent lethality was diminished with 0.25–0.5 μL of intravenous Apilic antivenom/μg honeybee venom. In vivo injection of 0.1–1 μg/g bee venom induced myotoxicity, hemoconcentration, paw edema, and increase of vascular permeability which were antagonized by Apilic antivenom. Cytotoxicity, assessed in renal LLC-PK1 cells and challenged with 10 μg/mL honeybee venom or melittin, was neutralized by preincubation with Apilic antivenom, as well the hemolytic activity. Apilic antivenom inhibited phospholipase and hyaluronidase enzymatic activities. In flow cytometry experiments, Apilic antivenom neutralized reduction of cell viability due to necrosis by honeybee venom or melittin. These results showed that this antivenom is effective inhibitor of honeybee venom actions. Thus, this next generation of Apilic antivenom emerges as a new promising immunobiological product for the treatment of massive, Africanized honeybee attacks.

Toxicological study of bee venom (Apis mellifera mellifera) from different regions of the province of Buenos Aires, Argentina

Samples of Apis mellifera mellifera venom from different hives in two regions of the Buenos Aires province and its pool were analyzed for their lethal potency, myotoxic, defibrinogenating, hemolytic and inflammatory-edematizing activity and for the histological alterations they produce in the heart, lungs, kidneys, skeletal muscle and liver of mice. In vitro studies focused on the venom's hemolytic activity in different systems and species (horse, man, sheep and rabbit), the cytotoxicity in cellular lines, and on the proteolytic and coagulant activity in plasma and fibrinogen. Hemolytic activity, either observed in vitro or in vivo, showed similar toxicity levels for all samples. Erythrocytes of different species varied in their sensitivity to the venom pool, equines being the most sensitive and sheep the most resistant to direct hemolytic action. Local and systemic myotoxicity was evidenced by either the elevation of serum creatine kinase and/or histopathological lesions, observed in different muscles. All samples caused significant pathological alterations; pulmonary, cardiac, renal and skeletal muscle lesions were substantive and can be related to the pathophysiological mechanisms of envenomation. The venoms from different apiaries and regions of the Buenos Aires province showed very similar toxicological characteristics. These results suggest that severity of envenomation in case of a swarming could therefore be more related to the number of bees than to the differential toxicity of the venom from different regions of the province. This is the first study on the toxicity and toxicological characteristics of Apis mellifera venom in Argentina.

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.

Recovery from AKI following multiple wasp stings: a case series

BACKGROUND AND OBJECTIVE

To observe the outcomes of AKI following multiple wasp stings.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Eighty-one patients (mean age ± SD, 45.5 ± 14.7 years; 55 men and 26 women; mean Acute Physiology and Chronic Health Evaluation II score, 16.85 ± 2.78) with AKI following multiple wasp stings between 1997 and 2011 were retrospectively analyzed. Data on their demographic characteristics, initial modalities of renal replacement therapy (RRT), urine output, serum creatinine, bilirubin, myoglobin, and other variables were collected. Renal outcomes included complete recovery of kidney function, CKD, and death. Subgroup analysis was performed according to initial modality of RRT in the first 48 hours, including continuous veno-venous hemofiltration (CVVH), intermittent hemodialysis (IHD), and CVVH plus plasma exchange (PE).

RESULTS

Of the 75 patients available for follow-up, 7 (9.3%) died, and 8 (10.7%, all in the IHD group) developed CKD. The average RRT time was 18.2 ± 8.4 days, and the average kidney function recovery time was 36.0 (29.0, 41.0) days. Subgroup analysis showed no difference in the mortality rates between the CVVH, CVVH + PE, and IHD groups (8.0%, 7.1%, and 11.1%, respectively; P>0.99). The recovery time for kidney function was significantly shorter in the CVVH and CVVH + PE groups than in the IHD group (31.9 ± 8.5 days, 28.6 ± 9.4 days, and 41.6 ± 8.1 days, respectively; P<0.001).

CONCLUSIONS

This is a large case series report on the outcomes of patients with AKI following multiple wasp stings. Most patients survived with complete recovery of their kidney function. Despite the lack of difference in mortality rates, the patients who began RRT with CVVH and CVVH + PE experienced a better and more rapid recovery of kidney function than those initiated with IHD.

Phenolic antioxidants tert-butyl-bisphenol and vitamin E decrease oxidative stress and enhance vascular function in an animal model of rhabdomyolysis yet do not improve acute renal dysfunction

Rhabdomyolysis (RM) caused by severe burn releases extracellular myoglobin (Mb) that accumulates in the kidney. Extracellular Mb is a pro-oxidant. This study tested whether supplementation with tert-butyl-bisphenol (BP) or vitamin E (Vit E, as α-tocopherol) at 0.12% w/w in the diet inhibits acute renal failure (ARF) in an animal model of RM. After RM-induction in rats, creatinine clearance decreased (p < 0.01), proteinuria increased (p < 0.001) and renal-tubule damage was detected. Accompanying ARF, biomarkers of oxidative stress (lipid oxidation and hemeoxygenase-1 (HO-1) gene and protein activity) increased in the kidney (p < 0.05). Supplemented BP or Vit E decreased lipid oxidation (p < 0.05) and HO-1 gene/activity and restored aortic cyclic guanylyl monophosphate in control animals (p < 0.001), yet ARF was unaffected. Antioxidant supplementation inhibited oxidative stress, yet was unable to ameliorate ARF in this animal model indicating that oxidative stress in kidney and vascular cells may not be causally related to renal dysfunction elicited by RM.

Mechanisms of bee venom-induced acute renal failure

The spread of Africanized bees in the American continent has increased the number of severe envenomation after swarm attacks. Acute renal failure (ARF) is one of the major hazards in surviving patients. To assess the mechanisms of bee venom-induced ARF, rats were evaluated before, up to 70 min and 24h after 0.5mg/kg of venom injection. Control rats received saline. Bee venom caused an early and significant reduction in glomerular filtration rate (GFR, inulin clearance, 0.84+/-0.05 to 0.40+/-0.08 ml/min/100g, p<0.0001) and renal blood flow (RBF, laser Doppler flowmetry), which was more severe in the cortical (-72%) than in the medullary area (-48%), without systemic blood pressure decrease. Creatine phosphokinase, lactic dehydrogenase (LDH) and serum glutamic oxaloacetic transaminase increased significantly, pointing to rhabdomyolysis, whereas serum glutamic pyruvic transaminase and hematocrit remained stable. Twenty-four hours after venom, RBF recovered but GFR remained significantly impaired. Renal histology showed acute tubular injury and a massive tubular deposition of myoglobin. Venom was added to isolated rat proximal tubules (PT) suspension subjected to normoxia and hypoxia/reoxygenation (H/R) for direct nephrotoxicity evaluation. After 60 min of incubation, 0.1, 2 and 10 microg of venom induced significant increases in LDH release: 47%, 64% and 86%, respectively, vs. 21% in control PT while 2 microg of venom enhanced H/R injury (85% vs. 55%, p<0.01). These results indicate that vasoconstriction, direct nephrotoxicity and rhabdomyolysis are important mechanisms in the installation of bee venom-induced ARF that may occur even without hemolysis or hypotension.

Wasp envenomation-induced acute renal failure: a report of three cases

Acute renal failure is an unusual complication of wasp stings. We report three cases who developed acute renal failure after multiple wasp stings (Vespa magnifica). Two patients had evidence of intravascular haemolysis and rhabdomyolysis whereas one patient investigation showed no evidence of intravascular haemolysis or rhabdomyolysis. All three cases had impaired liver functions. Oligo-anuria was seen in all three of the patients and all of them required dialytic support. One patient died of massive gastrointestinal bleeding while the remaining two recovered completely. Although acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of haemolysis or rhabdomyolysis, in some patients, renal failure may result from a direct nephrotoxic effect or acute interstitial nephritis from a hypersensitivity reaction to the wasp venom.

Cardiovascular profile after intravenous injection of Africanized bee venom in awake rats

The manifestations caused by Africanized bee stings depend on the sensitivity of the victim and the toxicity of the venom. Previous studies in our laboratory have demonstrated cardiac changes and acute tubular necrosis (ATN) in the kidney of rats inoculated with Africanized bee venom (ABV). The aim of the present study was to evaluate the changes in mean arterial pressure (MAP) and heart rate (HR) over a period of 24 h after intravenous injection of ABV in awake rats. A significant reduction in basal HR as well as in basal MAP occurred immediately after ABV injection in the experimental animals. HR was back to basal level 2 min after ABV injection and remained normal during the time course of the experiment, while MAP returned to basal level 10 min later and remained at this level for the next 5 h. However, MAP presented again a significant reduction by the 7th and 8th h and returned to the basal level by the 24th h. The fall in MAP may contribute to the pathogenesis of ATN observed. The fall in MAP probably is due to several factors, in addition to the cardiac changes already demonstrated, it is possible that the components of the venom themselves or even substances released in the organism play some role in vascular beds.

Inhibition of mammary carcinoma cell proliferation in vitro and tumor growth in vivo by bee venom

The possible tumor growth- and metastasis-inhibiting effects of bee venom in mice and in tumor cell cultures were studied. The tumor was a transplantable mammary carcinoma (MCa) of CBA mouse. Intravenous administration of bee venom to mice significantly reduced the number of metastases in the lung. However, subcutaneous administration of bee venom did not reduce the number of lung metastases, indicating that the antitumor effect of the venom could be highly dependent on the route of injection as well as close contact between the components of the venom and the tumor cells, as was shown by in vitro studies on MCa cells. We also observed variations in immunological parameter induced by bee venom. We proposed that bee venom has an indirect mechanism of tumor growth inhibition and promotion of tumor rejection that is based on stimulation of the local cellular immune responses in lymph nodes. Apoptosis, necrosis, and lysis of tumor cells are other possible mechanisms by which bee venom inhibits tumor growth.

Involvement of oxidative stress in bee venom-induced inhibition of Na+/glucose cotransporter in renal proximal tubule cells

1. The present study was conducted to examine the involvement of oxidative stress in bee venom-induced inhibition of the Na+/glucose cotransporter (alpha-methyl-d-glucopyranoside (alpha-MG) uptake), a typical functional marker of proximal tubules, in primary cultured rabbit renal proximal tubule cells (PTC). 2. Bee venom (> or = 1 microg/mL) increased lipid peroxide (LPO) formation over 30 min. The increase in [(3)H]-arachidonic acid (AA) release and LPO formation and the inhibition of alpha-MG uptake induced by bee venom (1 microg/mL) and melittin (a major component of bee venom; 0.5 microg/mL) were blocked by N-acetyl-l-cysteine, vitamin C and vitamin E, anti-oxidants. 3. Bee venom- and melittin-induced increases in LPO formation and inhibition of alpha-MG uptake were significantly prevented by mepacrine and AACOCF(3), phospholipase A(2) inhibitors. In addition, nordihydroguaiareic acid (a lipoxygenase inhibitor) and econazole (a cytochrome P-450 epoxygenase inhibitor), but not indomethacin (a cyclo-oxygenase inhibitor), prevented bee venom- and melittin-induced increases in LPO formation and inhibition of alpha-MG uptake. 4. Nordihydroguaiareic acid prevented bee venom- and melittin-induced increases in Ca(2+) uptake. Moreover, anti- oxidants significantly prevented bee venom- and melittin-induced increases in Ca(2+) uptake. 5. In conclusion, bee venom inhibits alpha-MG uptake via the phospholipase A(2)-oxidative stress-Ca(2+) signalling cascade in primary cultured rabbit renal proximal tubule cells.