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Survival After Massive (>2000) Africanized Honeybee Stings

Survival After Massive (>2000) Africanized Honeybee Stings We report the clinical case of a man who survived a massive attack of Africanized bees (> 2000 bee stings). The man experienced anaphylactic shock and multisystem organ failure (neurologic, hepatic, renal, and hematologic failure). He was treated with administration of dopamine hydrochloride, antihistaminic agents, corticosteroids, fluid and electrolyte replenishment, peritoneal dialysis, and plasmapheresis. No sequelae have been observed during follow-up.In 1956, the African bee (Apis mellifera scutellata) escaped from an apiculture laboratory in Brazil and subsequently extended its range to the rest of the Americas. Africanized bees arrived in Mexico in 1986 and in the United States in 1993.The African bee differs from its European counterpart, Apis mellifera ligustica, by its unusually aggressive behavior. Africanized bee attacks are characteristically massive, and, excluding the cases of pure anaphylaxis, the intensity of envenomation and the prognosis are directly associated with the number of bee stings. It has been reported that more than 250 bee stings are capable of causing death in humans.We report the clinical case of a man who survived a massive attack (>2000 stings) by Africanized bees.REPORT OF A CASEA 30-year-old male mountain climber was the victim of an attack by Africanized bees while exploring a cavern in San Luis Potosí state, located in the central highlands of Mexico. Immediately after the attack, the man had nausea, vomiting, distal paresthesia, muscular weakness, and generalized edema. Emergency medical assistance was requested by telephone. After 10 minutes, a paramedical team arrived and found a somnolent man with hypotension (blood pressure, 80/40 mm Hg), tachycardia (pulse rate, 110/min), and generalized edema. Multiple bee stings were noted on his body.Emergency treatment during the first hour after the insect attack consisted of the administration of subcutaneous epinephrine, 1 L of 0.9% isotonic sodium chloride, and 100 mg of intravenous hydrocortisone sodium succinate. The patient was transferred to the nearest hospital where saline solutions (125 mL/h), hydrocortisone (100 mg every 6 hours), and parenteral histamine type 1- and type 2-receptor blockers were administered. Oliguria (urine output, <10 mL/h) and stupor developed during the next 6 hours, together with persistent hypotension (average blood pressure, 80/40 mm Hg) unresponsive to the administration of dopamine hydrochloride and intravenous fluids. The patient was transferred to our hospital 12 hours after the insect attack.After the patient was admitted to the hospital, a physical examination revealed him to be semiconscious (Glasgow Coma Scale score, 5) and dehydrated with generalized edema. His blood pressure was 90/50 mm Hg, and his pulse rate was 120/min. Multiple bee-sting lesions were observed all over the trunk, extremities, and face (Figure 1). All the venom sacs were carefully removed and counted; more than 2000 bee stings were found. Some Africanized bees were also removed from the ears and nose. Abnormal laboratory test results at this time confirmed that the patient had multisystem organ failure, with a predominance of renal and hepatic involvement (Table 1).Patient's face following massive bee-sting attack.Laboratory Test Results at Hospital Admission and During First Week of Hospital StaySee table graphicHis initial treatment consisted of the administration of dopamine, antihistaminic agents, corticosteroids, fluid and electrolyte replenishment, and assisted mechanical ventilation; 48 hours after the insect attack, a rise in the serum urea nitrogen and creatinine levels was noted (Table 1), and peritoneal dialysis was begun.Plasmapheresis was initiated on the third day to try to remove circulating venom or the circulating mediators of inflammation potentially elicited by the venom itself. Plasmapheresis was repeated every other day for a total of 3 times. After a week, clinical and laboratory variables clearly improved (Table 1).Twenty-one days after the bee attack, the patient was discharged from the hospital in good health. No neurologic, renal, or hepatic sequelae have been observed during 4 months of follow-up.COMMENTAfricanized bees arrived in Mexico more than 10 years ago, but reports of massive attacks are uncommon. In contrast, a recent review highlights the increasing frequency of Africanized bee attacks in Mexico and in the southern United States.It is possible that many cases of massive bee attacks in Mexico remain unreported.Lethal attacks have been reported after "only" 250 stings by Africanized bees. An attack involving more than 1000 Africanized bee stings has been associated with thrombocytopenia, hemolysis, rhabdomyolysis, renal failure, acute myocardial infarction, and death in most of the affected persons.The clinical case reported here shows the aggressive behavior that Africanized bees exhibit. To our knowledge, this is the first case of a successful recovery of a patient with a massive bee envenomation of this degree.Our patient had acute renal and hepatic involvement soon after the bee attack. Direct toxic effects of the venom and muscle damage, evidenced in this case by the rise in creatine kinase levels, have been related to acute renal failure.Acute hepatic failure after honeybee envenomation has been associated with exposure to some toxic components of Africanized bee venom, such as melittin and phospholipase A2.Because the initial clinical manifestations of massive bee stings (ie, direct toxic effects) are indistinguishable from an acute anaphylactic reaction,accepted guidelines involve the immediate application of antianaphylactic measures, such as the administration of subcutaneous epinephrine, intravenous fluids, and corticosteroids.In cases of less severe bee stings, a careful clinical observation can help diagnose and treat an eventual anaphylactic reaction, which can be observed after only 1 bee sting.In our patient, survival was due to both the opportune treatment in the field and the appropriate management of short-term complications (such as acute renal and hepatic failure) in accordance with guidelines published elsewhere.In this patient, however, an important therapeutic measure was omitted: during the first minutes after the insect attack, the venom sacs were not extracted. We removed all the venom sacs after the patient was admitted to the hospital to reduce the access of venom to the circulation.In addition, we performed plasmapheresis in a desperate attempt to remove whatever venom remained in the circulation, as prognosis has been correlated with plasma venom concentrationsand our patient had suffered more than twice the reported median lethal dose of Africanized bee venom. Although we did not measure plasma venom concentrations, the use of plasmapheresis was associated with improved hemodynamic, neurologic, and hepatic function.A cause-and-effect relationship between plasmapheresis and clinical improvement in massive bee envenomation cannot be firmly established from a single clinical case. Our results suggest, however, that early plasmapheresis is helpful in the treatment of Africanized bee envenomation, probably through the direct effect of reducing the amount of circulating venom. Other possible mechanisms of action of plasmapheresis in cases of bee-sting envenomation could be the removal of the circulating mediators elicited by the venom itself. The role of peritoneal dialysis in cases of Africanized bee envenomation remains to be determined.MJSchumacherNBEgenSignificance of Africanized bees for public health: a review.Arch Intern Med.1995;155:2038-2043.CLTungetRFClarkInvasion of the "killer" bees: separating fact from fiction.Postgrad Med.1993;94:92-102.MSertTTetikerSPaydasRhabdomyolysis and acute renal failure due to honeybee sting as an uncommon cause [letter].Nephron.1993;65:647.REReismanInsect stings.N Engl J Med.1994;331:523-527.BSBochnerLMLichtensteinAnaphylaxis.N Engl J Med.1991;324:1785-1790.MJSchumacherMSTvetenNBEgenRate and quantity of delivery of venom from honeybee stings.J Allergy Clin Immunol.1994;93:831-835.FOFrancaLABenvenutiHWFanDRDos SantosSHHaimSevere and fatal mass attacks by "killer bees" (Africanized honey bees-Apis mellifera) in Brazil: clinicopathological studies with measurement of serum venom concentrations.QJM.1994; 87:269-282.Accepted for publication December 12, 1997.Corresponding author: Cristóbal Leonel Díaz-Sánchez, MD, Aristóteles 68, Polanco, México City, México 11560. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

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American Medical Association
Copyright
Copyright 1998 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
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2168-6106
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2168-6114
DOI
10.1001/archinte.158.8.925
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Abstract

We report the clinical case of a man who survived a massive attack of Africanized bees (> 2000 bee stings). The man experienced anaphylactic shock and multisystem organ failure (neurologic, hepatic, renal, and hematologic failure). He was treated with administration of dopamine hydrochloride, antihistaminic agents, corticosteroids, fluid and electrolyte replenishment, peritoneal dialysis, and plasmapheresis. No sequelae have been observed during follow-up.In 1956, the African bee (Apis mellifera scutellata) escaped from an apiculture laboratory in Brazil and subsequently extended its range to the rest of the Americas. Africanized bees arrived in Mexico in 1986 and in the United States in 1993.The African bee differs from its European counterpart, Apis mellifera ligustica, by its unusually aggressive behavior. Africanized bee attacks are characteristically massive, and, excluding the cases of pure anaphylaxis, the intensity of envenomation and the prognosis are directly associated with the number of bee stings. It has been reported that more than 250 bee stings are capable of causing death in humans.We report the clinical case of a man who survived a massive attack (>2000 stings) by Africanized bees.REPORT OF A CASEA 30-year-old male mountain climber was the victim of an attack by Africanized bees while exploring a cavern in San Luis Potosí state, located in the central highlands of Mexico. Immediately after the attack, the man had nausea, vomiting, distal paresthesia, muscular weakness, and generalized edema. Emergency medical assistance was requested by telephone. After 10 minutes, a paramedical team arrived and found a somnolent man with hypotension (blood pressure, 80/40 mm Hg), tachycardia (pulse rate, 110/min), and generalized edema. Multiple bee stings were noted on his body.Emergency treatment during the first hour after the insect attack consisted of the administration of subcutaneous epinephrine, 1 L of 0.9% isotonic sodium chloride, and 100 mg of intravenous hydrocortisone sodium succinate. The patient was transferred to the nearest hospital where saline solutions (125 mL/h), hydrocortisone (100 mg every 6 hours), and parenteral histamine type 1- and type 2-receptor blockers were administered. Oliguria (urine output, <10 mL/h) and stupor developed during the next 6 hours, together with persistent hypotension (average blood pressure, 80/40 mm Hg) unresponsive to the administration of dopamine hydrochloride and intravenous fluids. The patient was transferred to our hospital 12 hours after the insect attack.After the patient was admitted to the hospital, a physical examination revealed him to be semiconscious (Glasgow Coma Scale score, 5) and dehydrated with generalized edema. His blood pressure was 90/50 mm Hg, and his pulse rate was 120/min. Multiple bee-sting lesions were observed all over the trunk, extremities, and face (Figure 1). All the venom sacs were carefully removed and counted; more than 2000 bee stings were found. Some Africanized bees were also removed from the ears and nose. Abnormal laboratory test results at this time confirmed that the patient had multisystem organ failure, with a predominance of renal and hepatic involvement (Table 1).Patient's face following massive bee-sting attack.Laboratory Test Results at Hospital Admission and During First Week of Hospital StaySee table graphicHis initial treatment consisted of the administration of dopamine, antihistaminic agents, corticosteroids, fluid and electrolyte replenishment, and assisted mechanical ventilation; 48 hours after the insect attack, a rise in the serum urea nitrogen and creatinine levels was noted (Table 1), and peritoneal dialysis was begun.Plasmapheresis was initiated on the third day to try to remove circulating venom or the circulating mediators of inflammation potentially elicited by the venom itself. Plasmapheresis was repeated every other day for a total of 3 times. After a week, clinical and laboratory variables clearly improved (Table 1).Twenty-one days after the bee attack, the patient was discharged from the hospital in good health. No neurologic, renal, or hepatic sequelae have been observed during 4 months of follow-up.COMMENTAfricanized bees arrived in Mexico more than 10 years ago, but reports of massive attacks are uncommon. In contrast, a recent review highlights the increasing frequency of Africanized bee attacks in Mexico and in the southern United States.It is possible that many cases of massive bee attacks in Mexico remain unreported.Lethal attacks have been reported after "only" 250 stings by Africanized bees. An attack involving more than 1000 Africanized bee stings has been associated with thrombocytopenia, hemolysis, rhabdomyolysis, renal failure, acute myocardial infarction, and death in most of the affected persons.The clinical case reported here shows the aggressive behavior that Africanized bees exhibit. To our knowledge, this is the first case of a successful recovery of a patient with a massive bee envenomation of this degree.Our patient had acute renal and hepatic involvement soon after the bee attack. Direct toxic effects of the venom and muscle damage, evidenced in this case by the rise in creatine kinase levels, have been related to acute renal failure.Acute hepatic failure after honeybee envenomation has been associated with exposure to some toxic components of Africanized bee venom, such as melittin and phospholipase A2.Because the initial clinical manifestations of massive bee stings (ie, direct toxic effects) are indistinguishable from an acute anaphylactic reaction,accepted guidelines involve the immediate application of antianaphylactic measures, such as the administration of subcutaneous epinephrine, intravenous fluids, and corticosteroids.In cases of less severe bee stings, a careful clinical observation can help diagnose and treat an eventual anaphylactic reaction, which can be observed after only 1 bee sting.In our patient, survival was due to both the opportune treatment in the field and the appropriate management of short-term complications (such as acute renal and hepatic failure) in accordance with guidelines published elsewhere.In this patient, however, an important therapeutic measure was omitted: during the first minutes after the insect attack, the venom sacs were not extracted. We removed all the venom sacs after the patient was admitted to the hospital to reduce the access of venom to the circulation.In addition, we performed plasmapheresis in a desperate attempt to remove whatever venom remained in the circulation, as prognosis has been correlated with plasma venom concentrationsand our patient had suffered more than twice the reported median lethal dose of Africanized bee venom. Although we did not measure plasma venom concentrations, the use of plasmapheresis was associated with improved hemodynamic, neurologic, and hepatic function.A cause-and-effect relationship between plasmapheresis and clinical improvement in massive bee envenomation cannot be firmly established from a single clinical case. Our results suggest, however, that early plasmapheresis is helpful in the treatment of Africanized bee envenomation, probably through the direct effect of reducing the amount of circulating venom. Other possible mechanisms of action of plasmapheresis in cases of bee-sting envenomation could be the removal of the circulating mediators elicited by the venom itself. The role of peritoneal dialysis in cases of Africanized bee envenomation remains to be determined.MJSchumacherNBEgenSignificance of Africanized bees for public health: a review.Arch Intern Med.1995;155:2038-2043.CLTungetRFClarkInvasion of the "killer" bees: separating fact from fiction.Postgrad Med.1993;94:92-102.MSertTTetikerSPaydasRhabdomyolysis and acute renal failure due to honeybee sting as an uncommon cause [letter].Nephron.1993;65:647.REReismanInsect stings.N Engl J Med.1994;331:523-527.BSBochnerLMLichtensteinAnaphylaxis.N Engl J Med.1991;324:1785-1790.MJSchumacherMSTvetenNBEgenRate and quantity of delivery of venom from honeybee stings.J Allergy Clin Immunol.1994;93:831-835.FOFrancaLABenvenutiHWFanDRDos SantosSHHaimSevere and fatal mass attacks by "killer bees" (Africanized honey bees-Apis mellifera) in Brazil: clinicopathological studies with measurement of serum venom concentrations.QJM.1994; 87:269-282.Accepted for publication December 12, 1997.Corresponding author: Cristóbal Leonel Díaz-Sánchez, MD, Aristóteles 68, Polanco, México City, México 11560.

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Apr 27, 1998

References