International Journal of Health & Allied Sciences

CASE REPORT
Year
: 2014  |  Volume : 3  |  Issue : 1  |  Page : 56--59

Acute renal failure: A fatal complication following multiple hornet stings


Yatendra Singh, Subhash Chandra Joshi, Sandeep Raj Saxena, Mohammad Kalil 
 Department of Medicine, Government Medical College, Haldwani, Uttarakhand, India

Correspondence Address:
Yatendra Singh
Room No. 32, Sr Hostel Government Medical College, Haldwani - 263 139, Uttarakhand
India

Abstract

Hornet (wasp) stings are common worldwide. Most of the time they produce non fatal local allergic reactions, but sometimes can be fatal when mass stinging causes multisystem involvement We report a case of acute renal failure (ARF) following multiple hornet stings. A 28 year male presented with pain and swelling of the body following multiple hornet stings. After 3 days, he developed progressive decrease in urine output with dark colored urine. Physical examination revealed oedematous swelling mainly on exposed parts. On investigating, progressive elevations in renal function test was found. The markers of muscle injury were grossly elevated and liver enzymes were also deranged. These findings suggest multisystem involvement predominantly ARF secondary to rhabdomyolysis. After eight sessions of hemodialysis the patient improved completely. Timely intervention of multiple hornet stings causing ARF with multiorgan involvement by hemodialysis prevents mortality as well as other complications.



How to cite this article:
Singh Y, Joshi SC, Saxena SR, Kalil M. Acute renal failure: A fatal complication following multiple hornet stings.Int J Health Allied Sci 2014;3:56-59


How to cite this URL:
Singh Y, Joshi SC, Saxena SR, Kalil M. Acute renal failure: A fatal complication following multiple hornet stings. Int J Health Allied Sci [serial online] 2014 [cited 2019 Oct 23 ];3:56-59
Available from: http://www.ijhas.in/text.asp?2014/3/1/56/130618


Full Text

 Introduction



Wasp or hornet stings are a well known form of envenomation in the tropical countries. The insect order Hymenoptera consists of many medically important groups of stinging insects-Apoidea (bees), Vespoidea (paper wasps, hornets and yellow jackets commonly referred as wasps [1] ) and Formicidae (ants). [2] Hymenoptera venoms are concentrated and highly complicated mixtures of biochemically active agents. [3]

Hymenoptera venom allergy occasionally causes fatal reactions. The prevalence of systemic reactions (SRs) is 0.3-8.9%, with anaphylaxis in 0.3-42.8% of cases. [4] Hymenopteran venoms contain both speciesspecific components (Acetylcholine, antigen 5, biogenic amines, kinins) and shared components, most commonly enzymes, including hyaluronidase and phospholipases. [5],[6] Acute renal failure following wasp stings is an uncommon complication. Mass wasp stings lead to intravascular haemolysis, rhabdomyolysis, thrombocytopenia, acute tubular necrosis, and acute hepatic injury. Several mechanism have been proposed for acute renal failure like acute tubular necrosis, direct toxicity with venom and acute interstitial nephritis. [7],[8] We report a case of ARF followed by multiple hornet stings. Only few cases of this complication are reported from India and rarely from uttarakhand region. This case of multiple stinging with acute renal failure represents the fatal complication of envenomation.

 Case Report



A 28-year-old healthy male, who is a Gardener by occupation, presented with burning pain and swelling all over the body following multiple hornet (wasp) stings. When the patient was doing his work, the nest of the hornets (wasps) fell down from the tree and swarm of hornets (wasps) attacked him and caused the above injury mainly on exposed parts, like both limbs, upper part of chest and back. The lesions were mainly urticarial; some of them were having ulceration as well. The number was approximately 100 to 200. After 3 days of this incidence, the patient developed progressive decrease in urine output and renal failure. For these complications patient was referred to us. During these 3 days patient was given intravenous fluid, anti histaminic, corticosteroids and injection ceftriaxone 1 gm twice a day in some private hospital. The patient did not have any other significant illness in the past including hypertension, or any history of nephrotoxic drug intake. Examination revealed a pulse rate of 98/min, blood pressure of 138/90 mm of Hg and had swollen and edematous face, both upper limb, both lower limb and upper thorax. There were multiple sting marks over these sites [Figure 1] and [Figure 2]. Other systemic examination was clinically normal.{Figure 1}{Figure 2}

Investigations revealed a blood urea of 188 mg/dl, serum creatinine which rapidly worsened from 1.4 mg/dl to 7.2 mg/dl over next three days, the hematocrit was 48% and platelet count was 1.88 lakhs/mm 3 . The urine was dark brown colored and showed 2+ proteinuria and full field red blood cells (RBCs). Prothrombin time and activated partial thromboplastin time (APTT) was prolonged (14 with control of 12, 36 s with a control of 32 s). Bleeding and clotting time was normal. The rest of the biochemical analysis showed serum creatinine phospho kinase (CPK) of 33,00 IU/l, lactate dehydrogenase (LDH) of 4400 IU/l, AST 876 IU/l, ALT 600 IU/l. Serum potassium was 6.0 meq/l, serum sodium 143 meq/l, serum calcium 9.2 mg/dl, serum phosphorous 5.2 mg/dl and serum uric acid 7.3 mg/dl. Serum bilirubin was 4.2 mg% and urine myoglobin assay was more than 390 ng/ml. The ultrasound of the abdomen showed normal sized kidneys with normal echotexture and preserved corticomedullary differentiation. Liver was normal in size and echotexture [Table 1].{Table 1}

The patient had progressively worsening renal failure and remained oliguric (<200 ml/day) for 3 days, in spite of adequate hydration. Hence, the patient was initiated on intermittent hemodialysis on day 2 of admission and continued the antibiotics, antihistamines and corticosteroids till the signs of inflammation came down. The patient underwent eight sessions of hemodialysi on day 2, 4, 6, 8, 10, 12, 14 and 16. After about 2 weeks, the patient entered a diuretic phase and his urine output started improving and serum potassium, a PTT, and liver function tests became normal. After eighteen days his renal functions became absolutely normal (serum creatinine 0.9 mg/dl). Patient was discharged on 21 st day. Patient was given multivitamins, pantoprazole for 7 days and reviewed.

 Discussion



Wasp stinging usually occurs in the late summer and early fall, when large numbers of hungry yellow jackets are attracted to the food of humans eating outdoors. [9] Any wasp or bee will sting in defense if it is accidentally stepped on, swatted, or otherwise disturbed. In contrast, mass envenomations occur when stinging insects respond to a human intruder as a threat to their colony. [8] Wasp sting manifestations can range from nonspecific skin lesions to anaphylactic shock, especially in previously sensitized persons. While unexposed person can get cellular damage due to systemic toxicity following multiple stinging. [10] Wasp venom contains toxic melittin, apamine, phospholipases A1, hyaluronidase, acid phosphatase, histamine, and degranulating peptide mastoparan. [11] These components have direct and indirect cytotoxic (hepatic, renal and myocyte membrane), hemolytic, neurotoxic and vasoactive properties, which can cause intravascular haemolysis and rhabdomyolysis. [12]

The exact mechanism of rhabdomyolysis is not known but a direct toxic effect of venom on muscle is believed to be the main cause. [13] However, other mechanisms postulated for renal damage due to wasp stings are: (i) direct nephrotoxicity due to toxin; (ii) hypotension leading to ischemic tubular necrosis and (iii) nephropathy due to hemoglobinuria and myoglobinuria.

The manifestations other than renal failure include myocardial necrosis and infarction, centrilobular necrosis of liver, and thrombocytopenia as a result of direct platelet toxicity. [14],[15]

Many cases of rhabdomyolysis-associated ARF have been published, but those due to wasp stings are rare. The wasp venom has deleterious effect on renal tubules and glomeruli (albuminuria, haematuria and ARF), red blood cells (haemolysis, reticulocytosis, unconjugated hyperbilirubinaemia), muscles (rhabdomyolysis, elevated creatinine phosphokinase and lactate dehydrogenase, myoglobinuria) and liver (elevated transaminases, hypoalbuminaemia and prolonged prothrombin time). [10] Kularatne et al., had described similar multi-organ failure with high mortality following wasp poisoning owing to direct toxic effect. [16] Our patient had a rapidly worsening renal failure with markedly elevated serum levels of CPK and urinary myoglobin suggesting rhabdomyolysis. The elevated LDH levels points towards a hemolytic process. In view of the prolonged APTT disseminated intravascular coagulation was considered and, hence renal biopsy was not done. As the patient manifested all the stage of acute tubular necrosis and finally went to diuretic phase, the diagnosis of ATN was made, though the renal biopsy was not done.

Thus the clinical sequelae of multiple wasp stings can result in multisystem involvement ranging from intravascular hemolysis, rhabdomyolysis, acute renal failure, hepatic dysfunction, and occasionally thrombocytopenia and coagulopathy. Most common renal involvement is in the form of ATN. Initial management includes removal of stings at the earliest. When progressive renal failure ensues, intensive hemodialysis results in good renal recovery with return of renal functions to normal in majority of the survivors.

 Conclusion



It is important, not only to provide medical care as soon as possible to patients with multiple wasp bites, but also to anticipate major clinical problems due to systemic envenomation. ARF in these cases requires Intensive hemodialysis support and monitoring.

References

1Vetter RS, Visscher PK. Bites and stings of medically important venomous arthropods. Int J Dermatol 1998;37:481-96.
2Fitzgerald KT, Flood AA. Hymenoptera stings. Clin Tech Small Anim Pract 2006;21:194-204.
3Habermann E. Bee and wasp venoms. Science 1972;177:314-22.
4Bilo MB, Bonifazi F. The natural history and epidemiology of insect venom allergy: Clinical implications. Clin Exp Allergy 2009;39:1467-76.
5Bilo MB. Anaphylaxis caused by Hymenoptera stings: From epidemiology to treatment. Allergy 2011;66(Suppl 95):35-7.
6Meier J. Biology and distribution of hymenopterans of medical importance. In: Meier J, White J, editors. Handbook of clinical toxicology of animal venoms. Boca Raton, Florida: CRC Press; 1995. p. 341-7.
7Rejsman RE. Unusual reactions to insect stings. Curr Opin Allergy Clin Immunol 2005;5:355-8.
8Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999;170:223-7.
9Edwards R. Social Wasps; Their Biology and Control. East Grinstead. United Kingdom: Rentokil Ltd; 1980.
10Thiruventhiran T, Goh BL, Leong CL, Cheah PL, Looi LM, Tan SY. Acute renal failure following multiple wasp stings. Nephrol Dial Transplant 1999;14:214-7.
11King TP, Jim SY, Wittowski KM. Inflammatory role of two venom components of yellow jackets (Vespula vulgaris): A mast cell degranulating peptide mastoparan and phospholipase A1. Int Arch Allergy Immunol 2003;131:25-32.
12Koffler A, Friedler RM, Massry SG. Acute renal failure due to nontraumatic rhabdomyolysis. Ann Intern Med 1976;85:23-8.
13Kim YO, Yoon SA, Kim KJ, Lee BO, Kim BS, Chang YS, et al.Severe rhabdomyolysis and acute renal failure due to multiple wasp stings. Nephrol Dial Transplant 2003;18:1235.
14Ferreira DB, Costa RS, De Oliveira JA, Muccillo G. An infarct like myocardial lesion experimentally induced in Wistar rats with Africanized bee venom. J Pathol 1995;177:95-102.
15Joshua H, Ishay J. The anticoagulant properties of an extract from the venom sac of the oriental hornet. Toxicon 1975;13:11-20.
16Kularatne SA, Gawaramamana IB, de Silva PH. Severe multi-organ dysfunction following multiple wasp (Vespa affinis) stings. Ceylon Med J 2003;48:146-7