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Abstract
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Insect stings are a very common occurrence in tropical countries like India. These can occur as an accident or may be an occupational hazard (e.g. for those working in forests). In most cases, insect sting causes local reaction of short duration only. But in some cases, such sting may result in unusual systemic features1. Toxins in the venom of insects like wasp have the potential to cause severe multiorgan involvement 1. But practically, one or two stings are not so deadly; this multisystem involvement occurs only in severe envenomation resulting from multiple stings.1 We here present two cases of such grave consequences of insect sting.
We recently had two patients who presented to the emergency after getting stung by multiple hornets (Beng. Vimrul). One was a 60 year old male who presented on the 2nd day after the stings. He got stung by hornets while clearing weed from his garden. He had burning pain at the sites of sting and facial edema. He was at first managed as a case of acute anaphylaxis to insect venom. But the facial edema did not decrease with adrenaline or steroids, which were administered at the primary health centre and thus, he was referred to higher centre. On admission to our hospital, he had moderate facial edema. More than 20 sting marks were noted all over is body (Figure 1). It was also noted that he had decreased urine output and the urea/creatinine came as 120/4.8 mg/dl respectively. Urine RE/ME revealed WBC 6-8/Hpf and RBC 1-2/Hpf. By the same evening, the urea/creatinine rose to 148/6 mg/dl. His CPK level was 24.6 IU/L (N). There was no body ache. The patient was started on hemodialysis. Kidneys were normal in size and echotexture on Ultrasonography. His urine output started improving from the 6th day but even on 7th day, urea/creatinine was 95/5.2 mg/dl. Sodium/potassium remained normal throughout the episode. The patient needed multiple dialysis sessions over three weeks after which the urea/ creatinine normalized.
The 2nd case was a 54 year old male, who got stung by multiple hornets when he was cutting bamboo shoots in a grove. There were multiple stings all over his body and he also had anasarca at the time of presentation to our hospital (3rd day after the incident). There was no body ache. His urine output was 100 ml in 24 hours at the time of admission. Urine was normal in colour. His Urea/Creatinine at presentation (3rd day) was 76/10.35 mg/ dl respectively. Serum CPK was 1682 IU/L. Urine RE/ME revealed protein 1+, RBC 10-12/Hpf and WBC 4-8/Hpf. The patient was immediately started on supportive treatment including hemodialysis. His urine output started improving after 7th day. Urea/creatinine on 7th day was still 58/5.78 mg/dl. Ultrasonography of abdomen revealed normal sized kidneys with normal echotexture. Serum CPK normalized by 10th day. This patient also needed multiple hemodialysis sessions over 15 days.
Both of these patients had no prior history of diabetes, hypertension or any kidney disease. They were not known to be allergic to any insects. For both of them, blood hemoglobin levels remained normal throughout.
Common stinging insects of the tropical countries include bees, wasps and rarely, hornets2. These stings cause significant local inflammatory reaction and occasionally, IgE mediated allergic reactions2. Rarely, significant systemic involvement has also been reported2. In contrast to animal or snake bite, in case of insect stings, the envenomation and extent of systemic involvement is often determined by the number of stings.2 In both of our patients, multiple hornet stings were followed by acute kidney injury (AKI)...
Language: en |