Nigerian Journal of Paediatrics

A Call for sting treatment protocol Case report of a 3 year old with massive bee sting resulting in acute kidney injury

Niger J Paediatr 2016; 43 (3): 231 – 233

CASE REPORT

Jimoh AO

A Call for sting treatment protocol:

Akuse RM

Bugaje MA

Case report of a 3 year old with

Mayaki S

massive bee sting resulting in acute

kidney injury

DOI:http://dx.doi.org/10.4314/njp.v43i3.14

Accepted: 7th June 2016

Abstract : Acute Kidney Injury in

developed clinical features of in-

children following bee sting en-

travascular haemolysis, rhabdo-

Jimoh AO

(

)

venomation is rare and survival is

myolysis, hypertension and acute

Akuse RM, Bugaje MA, Mayaki S

hinged on early recognition and

renal failure. Laboratory findings

Department of Paediatrics,

Ahmadu Bello University Teaching

prompt appropriate management.

were in keeping with clinical pres-

Hospital, Zaria

This report is aimed at raising

entation. Despite supportive man-

Email: oyewoao@yahoo.co.uk

awareness

among

healthcare

agement,

serum biochemistry

workers, of one of the systemic

worsened necessitating haemodi-

effects of massive bee sting and

alysis. Massive bee sting enveno-

the need to develop sting treat-

mation can cause systemic reac-

ment protocol. A three year old

tions and organ dysfunctions. To

preschooler was attacked by a

improve the overall clinical out-

swarm of bees, receiving over

come, sting treatment protocol is

150stings. Initial clinical features

advocated.

were allergic response involving

the head, face and tongue for

Key Words: Bee sting envenoma-

which he had first aid in a primary

tion, acute kidney injury, sting

healthcare facility and thereafter

treatment protocol, rhabdomyoly-

sent home.

Few hours later he

sis, myoglobinuria, haemodialysis.

Introduction

breathing, vomiting, diarrhoea, or loss of consciousness.

He had no prior history of hospital admissions and no

Very little is known about massive envenomation by

family history suggestive of atopy, kidney disease, or

hymenoptera (bee), especially among children. Hymen-

hypertension.

optera envenomation may result in systemic damage but

with early commencement of standard care, chances of

On admission, he was in painful distress and there was

survival are increased. However in the absence of treat-

massive oedema involving the scalp, tongue and face

ment protocol, appropriate management and survival is

with inability to open both eyes. There were 155 stings

unlikely. There is a need to raise awareness among

marks with tender ecchymotic lesions on the affected

healthcare providers on the need to develop bee-sting

areas. He was not in respiratory distress, not jaundiced

treatment protocol that can be initiated rapidly at all

but mildly pale. He had sinus tachycardia (pulse rate

levels of health care service. We report a case of a three

100/min), systolic hypertension (BP- 100/60 mmHg)

year old boy who developed acute kidney injury follow-

and tachypnoea of 40cycles/min. There were no palpa-

ing massive bee sting envenomation.

bly enlarged organs. Anthropometry was within normal

limits. While on admission he had one episode of gener-

Case

alized tonic clonic convulsion, controlled with paralde-

hyde. He also had an episode of epistaxis with estimated

A three year old boy presented to the Emergency Paedi-

blood loss of 100mls. The scalp lesions ulcerated and he

atric Unit (EPU) of our facility 22 hours after attack by a

developed a fever but the swollen head, face and tongue

swarm of bees along a bush path. The bees covered his

gradually reduced in size.

head and face, with some entering his mouth. He was

rescued by a passerby 30minutes later and immediately

Initial laboratory work up revealed: packed cell volume

(PCV) 33%, total leukocyte count 8.3 x10 /l with left

taken to a primary health care centre (PHC) where over

150 stingers were immediately removed. The affected

shift. Platelets were initially normal. There was in-

sites were washed with antiseptics and oral analgesics,

creased prothrombin time (PT) and Kaolin Cephalin

antacids and antibiotics prescribed, and then sent home.

Clotting Time (KCCT): - 17 and 38 seconds respectively

Eight hours later he developed swelling of the head and

(control: 14 and 35 seconds). The initial serum biochem-

face and for 22 hours post the incident, he did not pass

istry showed deranged serum urea and serum creatinine

urine. There was no history of jaundice, difficulty in

(Table 1). Urinalysis revealed proteinuria and haema-

232

turia. Ultrasonography showed normal kidneys and pelvi

cells, causing pain and provoking haemolysis and rhab-

-calyceal system. Clinically, he was assessed to have a

domyolysis. The sudden rise of our patient’s serum

systemic inflammatory reaction to bee sting venom-

creatinine suggesting rhabdomyolysis and fall in haemo-

rhabdomyolysis and acute kidney injury.

globin with haemoglobinuria can be explained by this

Resuscitation at the EPU included challenging the kid-

mechanism of bee sting envenomation. An assay of the

neys with intravenous fluid and thereafter he passed

creatine phosphokinase would have further reinforced

30mls of coca-coloured urine (maintenance fluid intake

the evidence, however financial constraints prevented

was based on daily requirement); intravenous hydrocor-

that. Serial blood chemistry studies and serum levels of

tisone, antihistamine, tetanus toxoid (intramuscular),

haemoglobin and myoglobin performed over a period of

analgesic and antibiotics. Nasogastric tube was inserted

hours to days will reveal whether toxic venom effects

for feeding and urethral catheter for continuous urinary

have occurred. The renal damage, as seen in this report,

output monitoring.

could be as a result of either direct nephrotoxicity due to

toxin,

hypotension leading to ischemic tubular necro-

sis or nephropathy due to haemoglobinuria and myoglo-

Despite adequate diuresis and improving blood pressure,

binuria. Direct toxin mediated cellular damage in mas-

serum biochemistry worsened with rapidly increasing

levels of serum urea, creatinine and worsening acidosis

sive envenomation has also been found to cause dis-

(Table 1); PCV dropped to 20.1% and platelet count

seminated intravascular coagulopathy, cardiovascular

dropped from 249 x 10 /L to 59 x 10 /L. At admission,

abnormalities, hepatic damage and neurological defi-

cits of different degrees.

9,10

he had an estimated glomerular filtration rate (GFR) of

25.3 ml/min/1.73m which worsened over days to

11.1ml/min/1.73m . He had haemodialysis with intra-

The management of massive bee envenomation is

dialysis blood transfusion and subsequent improvement

mainly supportive with no specific anti-venom being

available . Rapid removal of stingers is advocated as

1,3

in serum biochemistry (Table 1) and general condition.

However, despite counselling, the parents declined con-

90% of the venom sac contents are delivered in 20 sec-

onds with delivery completed in one minute . Delay in

tinuation of management due to financial constraints and

discharged against medical advice.

removal leads to increased weal size and increase in

envenomation. This was the case in our patient as the

Table 1 shows worsening serum biochemistry (days 1, 5

stingers were removed almost an hour after the sting.

and 10). Values seen on the day 12 are post haemodialy-

The cumulative dose of the multiple stings account for

the morbidity and mortality.

sis

Table 1: Serum biochemistry results for days 1, 5, 10

Early treatment with steroids and antihistamines, copi-

and 12

ous saline hydration for intravenous volume replacement

Parameters

Day 1

Day 5

Day 10

Day 12

and sodium bicarbonate for urine alkalization is ad-

vised.

3,4,13,14,15

Treatment of acute kidney injury follow-

Urea (mmol/l)

27.1

6.5

43.8

40.0

ing bee stings with haemodialysis, hemofiltration or

Sodium(mmol/l)

137.0

120.0

131.0

133.0

peritoneal dialysis has been reported,

13,14

Potassium(mmol/l)

4.8

2.9

4.3

although ex-

Chloride(mmol/l)

100.0

83.0

94.0

93.0

change blood transfusion or plasmapharesis is equally

Bicarbonate(mmol/l)

22.0

15.0

11.0

16.0

effective because it directly reduces the circulating me-

diators of inflammation caused by the venom.

Creatinine (µmol/l)

165.0

353.0

377.0

236.0

In this

patient, supportive measures and haemodialysis, in addi-

tion to aggressive hydration and intensive wound care

formed the basis for therapy. Patients who develop res-

Discussion

piratory arrest require ventilator support while vasopres-

sors can be used to provide vascular support. The pa-

This case demonstrates that bee envenomation can cause

tient’s renal function started improving after commenc-

severe systemic effects other than the commonly re-

ing haemodialysis but further monitoring could not be

ported anaphylaxis. Bees, unlike wasps, leave stings

done because parents requested discontinuation of man-

behind which release large amounts of venom, 50 – 140

agement on account of financial constraints.

mcg/sting leading to a spectrum of reactions from mild

local allergic reactions to large local reactions and in

Literature search shows as few as 30-50 stings in chil-

some cases systemic toxic reaction.

Systemic toxic

dren carries grave prognosis while very sensitive indi-

reactions, such as acute kidney injury, hepatic damage,

viduals may develop fatal anaphylaxis even after just

one bite.

3,16

neurological deficit, disseminated intravascular coagulo-

Our patient had over 150 stings and sur-

pathy, hypotension, bronchoconstriction and even death,

vived. The time between the accident and medical treat-

are seen in cases of massive bee envenomation.

ment, and the prompt removal of stingers seem to be

important in determining our patient’s prognosis.

3, 4,15, 17

The clinical presentation of this patient can be explained

Prognosis is also improved when systemic toxic effect is

by the effect of the biochemical components of bee

anticipated, with anticipatory management instituted.

venom

[2, 3]

The peptides and phospholipids contained in

the venom actively cause destruction of red blood cells,

release of histamine and other components by mast

233

Conclusion

management cannot be overemphasized.

In conclusion, multiple hymenoptera envenomation is

Authors’ contribution

not an innocuous condition, yet manifestation can be

All the authors participated in the conception, literature

delayed and can be grave resulting in deadly conse-

search, preparation, reviewing and writing of the manu-

quences. Survival is hinged on early commencement of

script.

appropriate management. There is therefore a need to

Conflict of interest: None

develop sting treatment protocols and increase public

Funding: None

education. Meanwhile, the need for anticipatory

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