Acute Renal Failure and/or Rhabdomyolysis due to Multiple Bee Stings: A Retrospective Study

500 bee stings in a single fatal encounter

Incidences of multiple bee stings have been increasing globally; the substantial amount of bee venom injected in such incidents can result in anaphylactic shock, rhabdomyolysis and renal failure, proving fatal in some cases. While anaphylactic reactions are more common and have established treatment protocols, inflammatory response induced by the venom demands a tailored approach. Here we report a case of a 70-year-old male in India who succumbed from approximately 500 bee stings. Based on our literature review, this case stands out as one of the first reported fatalities caused by 500 bee stings in our country. The unidentified species of bees in this case makes management of such bee venom-related toxic reactions more difficult. This report emphasises the importance of prompt and appropriate interventions.

Unusual case of recurrent hypoglycaemia in multiple bee sting envenomation

A bee sting can result in allergic and toxin-mediated local manifestations like pain, swelling, redness and itching to serious systemic effects like acute kidney injury (AKI), pancreatitis, Kounis syndrome and stroke. Melittin and phospholipase A2, which make up 62% of honeybee venom, have vasoactive, haemolytic properties causing severe AKI. Its role in lowering blood glucose in diabetics is an interesting research topic. We report an elderly herdsman, a known diabetic on irregular oral hypoglycaemic drugs, who presented with altered mental status due to hypoglycaemia. On further prodding, a recent multiple bee sting attack 5 days ago was found which was followed by altered coloured urine for 2 days for which no medical attention was sought. Additional analyses revealed reticulocytosis, azotemia and high serum creatine phosphokinase. The patient was treated with dextrose infusion, antihistamines, fluids and haemodialysis. Renal failure resolved completely and the patient was discharged in a stable condition.

Biochemical characterization of a phospholipase A2 homologue from the venom of the social wasp Polybia occidentalis

Background

Wasp venoms constitute a molecular reservoir of new pharmacological substances such as peptides and proteins, biological property holders, many of which are yet to be identified. Exploring these sources may lead to the discovery of molecules hitherto unknown. This study describes, for the first time in hymenopteran venoms, the identification of an enzymatically inactive phospholipase A₂ (PLA₂) from the venom of the social wasp Polybia occidentalis.

Methods

P. occidentalis venom was fractioned by molecular exclusion and reverse phase chromatography. For the biochemical characterization of the protein, 1D and 2D SDS-PAGE were performed, along with phospholipase activity assays on synthetic substrates, MALDI-TOF mass spectrometry and sequencing by Edman degradation.

Results

The protein, called PocTX, was isolated using two chromatographic steps. Based on the phospholipase activity assay, electrophoresis and mass spectrometry, the protein presented a high degree of purity, with a mass of 13,896.47 Da and a basic pI. After sequencing by the Edman degradation method, it was found that the protein showed a high identity with snake venom PLA₂ homologues.

Conclusion

This is the first report of an enzymatically inactive PLA₂ isolated from wasp venom, similar to snake PLA₂ homologues.

Histopathological and ultrastructural changes experimentally induced by bee venom in seminiferous epithelium via structural-functional alteration of Sertoli cells

We tested here the ability of bee venom (BV) to interfere with spermatogenesis in rats in two experimental conditions. The histopathological changes were assessed with brightfield microscopy using a novel staining technique, based on methylene blue, orange G and ponceau xylidine. Transmission electron microscopy was also used to identify fine subcellular changes. BV injection for 30days in daily doses of 700μg BV/kg resulted in reducing testicular weight, along with significant larger diameters of seminiferous tubules and reduced number of Sertoli cells (SCs). SCs were vacuolated, detached from the basement membrane, many necrosed, leading to the basement membrane denudation. Germ cells layers were separated by empty spaces conferring a rarefied aspect to the tissue, and spermatids were detached into lumen. Thus, the seminiferous epithelium was significantly thinned. Many Leydig cells (LCs) were in a necrotic state, with disrupted plasma membrane and without smooth endoplasmic reticulum. The acute treatment with a single LD50 of 62mgBV/kg, was followed by focal disruptions of the basement membrane and localized areas of necrosis, mainly affecting the SCs. Most of the observed SCs as well as some spermatogonia were highly vacuoled, empty spaces being observed within the epithelium. The SCs count was significantly decreased. Spermatids had also the tendency of separation from the SCs, and the significant larger diameter of the tubules found was associated with a thicker epithelium. Many LCs were necrosed, with disrupted plasma membrane, swollen mitochondria, no endoplasmic reticulum and implicitly showing rarefied cytoplasm. We concluded that BV was a testicular toxicant affecting both the LCs and the seminiferous tubules. The SCs cells represented the primary target site of BV whose effects were next extended upon the germ cells. In all cells, BV triggered unspecific degenerative changes that could impaire spermatogenesis. The present study also proposes an alternative staining technique very useful in assessing the histopathological aspects of spermatogenesis.

Non-traumatic rhabdomyolysis: Background, laboratory features, and acute clinical management

Rhabdomyolysis is a relatively rare condition, but its clinical consequences are frequently dramatic in terms of both morbidity and mortality. Although no consensus has been reached so far about the precise definition of this condition, the term rhabdomyolysis describes a rapid breakdown of striated, or skeletal, muscle. It is hence characterized by the rupture and necrosis of muscle fibers, resulting in release of cell degradation products and intracellular elements within the bloodstream and extracellular space. Notably, the percentage of patients with rhabdomyolysis who develop acute kidney injury, the most dramatic consequence, varies from 13% to over 50% according to both the cause and the clinical and organizational setting where they are diagnosed. Despite direct muscle injury (i.e., traumatic rhabdomyolysis) remains the most common cause, additional causes, frequently overlapping, include hypoxic, physical, chemical or biological factors. The conventional triad of symptoms includes muscle pain, weakness and dark urine. The laboratory diagnosis is essentially based on the measurement of biomarkers of muscle injury, being creatine kinase (CK) the biochemical "gold standard" for diagnosis, and myoglobin the "gold standard" for prognostication, especially in patients with non-traumatic rhabdomyolysis. The essential clinical management in the emergency department is based on a targeted intervention to manage the underlying cause, combined with infusion of fluids and eventually sodium bicarbonate. We will present and discuss in this article the pathophysiological and clinical features of non-traumatic rhabdomyolysis, focusing specifically on Emergency Department (ED) management.

Animal toxins and renal ion transport: Another dimension in tropical nephrology

Renal vascular and tubular ion channels and transporters involved in toxin injury are reviewed. Vascular ion channels modulated by animal toxins, which result in haemodynamic alterations and changes in blood pressure, include ENaC/Degenerin/ASIC, ATP sensitive K channels (KATP ), Ca activated K channels (Kca) and voltage gated Ca channels, mostly L-type. Renal tubular Na channels and K channels are also targeted by animal toxins. NHE3 and ENaC are two important targets. NCC and NKCC may be involved indirectly by vasoactive mediators induced by inflammation. Most renal tubular K channels including voltage gated K channels (Kv1), KATP , ROMK1, BK and SK are blocked by scorpion toxins. Few are inhibited by bee, wasp and spider venoms. Due to small envenoming, incomplete block and several compensatory mechanisms in renal tubules, serum electrolyte charges are not apparent. Changes in serum electrolytes are observed in injury by large amount of venom when several channels or transporters are targeted. Envenomings by scorpions and bees are examples of toxins targeting multiple ion channels and transporters.

Possible complication of bee stings and a review of the cardiac effects of bee stings

We report the case of a patient who, ∼3 weeks after multiple bee stings, developed a prolonged heart block, syncope and cardiac arrest. This required a temporary pacemaker to be implanted, which was later replaced with a permanent pacemaker. An ECG taken following surgery for a fractured humerus 6 years earlier was reportedly normal. The patient had been a rubber tapper who walked ∼1.5 km/day, but after the bee attack he was no longer able to walk or get up from the bed without experiencing syncope. We presume that the bee venom caused these signs, as well as the resulting heart block, which persisted long after the bee sting had subsided. Since his coronary angiogram was normal we believe he had a Kounis type involvement of the cardiovascular system, namely profound coronary spasm that caused complete heart block that did not recover. Another probable reason for the complete heart block could have been that the bees had consumed the pollen of a rhododendron flower, causing 'grayanotoxin' poisoning and severe heart block. The other effects of bee sting are discussed briefly.

[Mortal poisoning by bee stings in a child: Study of a case observed in the regional hospital of Maradi (Niger)]

We report a fatal case due to a massive attack by a swarm of bees in a nine-year-old child. The accident was fatal because of two aggravating factors: the cephalic location and the large number of stings (about 300). Complications were coagulopathy, anemia, hemorrhage, coma, and oligoanuria. Support was symptomatic at a facility second level. The outcome was fatal within 14 days. In view of the encountered difficulties, we recommend to build written protocols for the management of envenomation in any health training reference.

Clinical predictors of acute kidney injury following snake bite envenomation

Background:

Snake bite envenomation is a major public health concern in developing countries. Acute kidney injury (AKI) is as important cause of mortality in patients with vasculotoxic snake bite.

Aims:

This study was to evaluate the clinical profile of snake bite patients and to determine the predictors of developing AKI following snake bite.

Materials and Methods:

Two hundred and eighty-one patients with snake envenomation were included. Eighty-seven patients developed AKI (Group A) and 194 (Group B) did not. History, examination findings and investigations results were recorded and compared between the two groups.

Results:

In group A, 61 (70.11%) patients were male and in group B, 117 (60.30%) patients were male. Out of 281 patients, 232 had cellulitis, 113 had bleeding tendencies, 87 had oliguria, 76 had neuroparalysis, and 23 had hypotension at presentation. After multivariate analysis, bite to hospital time (P = 0.016), hypotension (P = 0.000), albuminuria (P = 0.000), bleeding time (P = 0.000), prothrombin time (P = 0.000), hemoglobin (P = 0.000) and total bilirubin (P = 0.010) were significant independent predictors of AKI.

Conclusions:

AKI developed in 30.96% of patients with snake bite, leading to mortality in 39.08% patients. Factors associated with AKI are bite to hospital time, hypotension, albuminuria, prolonged bleeding time, prolonged prothrombin time, low hemoglobin and a high total bilirubin.