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| CME IN IMAGES |
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| Year : 2017 | Volume
: 15
| Issue : 1 | Page : 68-69 |
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Rhabdomyolysis following hymenoptera envenomation
Shalabh Arora1, Maansi Sethi2, Ajay Kumar Mishra1
1 Department of Internal Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
2 Department of Ophthalmology, Lady Hardinge Medical College, New Delhi, India
| Date of Web Publication | 17-Feb-2017 |
Correspondence Address:
Shalabh Arora
Department of Internal Medicine, Christian Medical College Hospital, Vellore - 632 004, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0973-4651.200306
How to cite this article:
Arora S, Sethi M, Mishra AK. Rhabdomyolysis following hymenoptera envenomation. Curr Med Issues 2017;15:68-9 |
| Case Scenario | |  |
A 16-year-old male presented with a history of having contracted multiple bee stings while climbing a tree a day earlier when he accidentally struck a beehive. He was bitten by numerous bees on the head, neck, and exposed parts of the hands and feet, following which he developed progressive swelling of the face, lips, and around the eyes, with the inability to open eyes and difficulty opening mouth.
On examination, he had tachycardia (heart rate, 132 bpm), tachypnea (respiratory rate, 26/min), and hypotension (90/60 mmHg). There was marked periorbital and perioral edema with matted swelling of the eyelids, mouth opening <1 cm (Mallampati class = 4). In addition, there were multiple sting marks over the face, scalp, neck, upper chest, and hands [Figure 1]. He was unable to open eyes or speak due to pain; rest of the systemic examination was unremarkable.
| Questions | | |
- What are the medically important members of the order Hymenoptera?
- What are the clinical manifestations following bee sting?
- What are the steps in the management of bee sting envenomation?
| Answers | | |
- Order Hymenoptera includes winged insects that are subdivided based on the presence of a waist. Among these, the Apidae family (honeybees [Apis mellifera] and bumble bees) and Vespidae family (yellow jackets, yellow hornets, white-faced hornets, and paper wasps) insects are medically important. Honeybees have a barbed stinging apparatus that becomes lodged in the skin and rips away along with the venom sac when the insect bites. The venom, which continues to be released for several seconds, is a mix of several vasoactive amines, small polypeptides, and enzymes. Melittin constitutes roughly 50%, whereas the highly immunogenic phospholipase A2 constitutes 12% of dry weight of the honeybee venom [1]
- The clinical manifestations can vary from nonallergic minor local reactions (as seen in most patients) to anaphylaxis with severe systemic manifestations in patients with venom allergy
Nonallergic local reaction manifests as an uncomplicated local reaction that comprises intense local pain and erythema immediately following the sting. Large local reactions can also occur, that peak between 24 and 48 h and then subside.
Anaphylactic reaction is an immediate venom-specific IgE antibody-mediated Type 1 hypersensitivity reaction that has been reported to occur in 0.3%–3% of all Hymenoptera stings. It has a varied presentation that includes generalized urticaria, angioedema, upper airway obstruction due to edema of the pharynx and epiglottis, and circulatory collapse, leading to death.[2] Rhabdomyolysis, myocarditis, and acute kidney injury are uncommon manifestations that usually occur with multiple bee stings.[3] Rhabdomyolysis, which is a rare complication, was present in our patient [Figure 2]. - Management - Management of bee sting comprises the following:
 | Figure 2: Serial creatine phosphokinase (U/L) and platelet count (per cu mm) during hospital stay.
Click here to view |
- Prompt removal of any insects or stingers that may still be attached to the skin or entrapped in the patient's clothing
- Cold compresses usually suffice for uncomplicated local reactions, whereas large local reactions sometimes require oral antihistamines, nonsteroidal anti-inflammatory drugs, and short-course oral steroids
- Acute management of venom-induced anaphylaxis is similar to the treatment of anaphylaxis from other causes; treatment is largely supportive in the absence of a specific antitoxin. Epinephrine, antihistamines, intravenous (IV) steroids, crystalloids, and inotropic support are the cornerstone of successful resuscitation
- Patients developing rhabdomyolysis benefit from aggressive fluid replenishment with a target urine output of 200 mL/h. Patients with a diagnosis of venom allergy are candidates for venom immunotherapy.
| Discussion | | |
Upon arrival to the emergency department, this patient was initially managed with injection hydrocortisone 200 mg IV, injection pheniramine 25 mg IV, and four doses of injection adrenaline 1 mg intramuscular. His laboratory parameters revealed features of rhabdomyolysis, myocarditis, ischemic hepatitis, and coagulopathy. He underwent an emergency tracheostomy for impending airway obstruction and was managed in the intensive care unit with ventilator support and close monitoring. Acute kidney injury due to rhabdomyolysis was successfully prevented with vigorous hydration and urine alkalinization. He was discharged home after a hospital stay of 10 days and was stable at a follow-up visit 2 weeks later.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Spillner E, Blank S, Jakob T. Hymenoptera allergens: From venom to “venome”. Immunother Vaccines 2014;5:77.  |
| 2. | Golden DB. Insect sting anaphylaxis. Immunol Allergy Clin North Am 2007;27:261-72, vii. |
| 3. | Deshpande PR, Farooq AK, Bairy M, Prabhu RA. Acute renal failure and/or rhabdomyolysis due to multiple bee stings: A retrospective study. N Am J Med Sci 2013;5:235-9. |
[Figure 1], [Figure 2]
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