https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/208 Sun, 30 Apr 2017 15:27:23 +0000 Massive envenomations by bees are capable of causing multiorgandysfunction as a result of direct toxic effects of the largevenom load received. Although all varieties of honey bee havethe potential for these attacks, the Africanized honey bee (Apismellifera scutellata) is the most commonly implicated subspecies.In the United States, the Africanized strain is found primarilyin the southwestern states and is known for its highly defensivebehavior if disturbed. Mechanisms behind the multiorgan dysfunctionproduced by these mass envenomations are not clearly understood.We present a case of an 8-year-old boy who was stung by multiple bees and developed progressive upper-body swelling andsystemic manifestations of mass envenomation including rhabdomyolysis,renal insufficiency, and a transient transaminase elevation. Address for Correspondence:Dr. Farzana Islam, Department of Paediatric Nephrology, Block: D, 3rd Floor, Bangabandhu Sheikh Mujib Medical University. Shahbagh, Dhaka-1000, Bangladesh, Mobile: +8801718011237, Email: dr.farzanaislamsilvi@yahoo.com   Stinging events involving honeybees and wasps are rare; most deaths or clinically important incidents involve very few stings (<10) and anaphylactic shock. However mass stinging events can prove life threatening via toxic action of the venom when injected in large amounts.1 Several types of uncommon reactions have been described including serum sickness, renal diseases, respiratory and neurological manifestations, hepatic dysfunction and delayed hypersensitivity phenomena.2  Case Report Arterial blood gas (ABG) revealed pH 7.35, paO2 80 mmHg, paCO2 34, HCO3 18 meq/L. Urine examination: color was reddish, appearance was initially clear then hazy, albumin ++, pus cells 2-6 /hpf, RBCs 35-45/hpf, urine hemoglobin +, urine culture - sterile.Laboratory findings were consistent with intravascular hemolysis, rhabdomyolysis, acute renal failure and hepatic dysfunction. Patient was treated with fluid restriction, diuretics, antibiotics, steroids, antihistamins and sodium bicarbonate. Ultimately he needed four sessions of hemodialysis after which he gradually improved and renal function returned to near normal by day fifteen.   This case demonstrates that multiple bee stings may cause rhabdomyolysis and hemolysis with consequent ATN. Components of venom include toxic surface-active polypeptides (mellitin and apamin), enzymes (phospholipase A2 and hyaluronidase) and low molecular weight agents (histamine and aminoacids). Mellitin and phospholipase are important components causing rhabdomyolysis following a toxic action on striated muscles which also acts on the red cell membrane and provokes hemolysis.3 The elevated levels of enzymes CPK and aspartate-aminotransferase suggest the existence of rhabdomyolysis and hemolysis is suggested by anemia, unconjugated hyperbilirubinemia, reticulocytosis, increased serum LDH and hemoglobinuria.3  The mortality associated with Africanized honeybee attacks is primarily the result only of the number of the number of stings.5 A number of about 500 stings have been considered necessary to cause death by direct toxicity, but as few as 30-50 stings have proved fatal in children.3 Our patient had about 200 stings and survived with complete renal recovery. The primary therapeutic goal is to prevent the factors that cause ARF, i.e. volume depletion, tubular obstruction, aciduria and free radical release. Patients are administered saline for intravascular volume expansion and sodium bicarbonate for urine alkalization (to urine pH level above 7). The ideal fluid regimen for patients with rhabdomyolysis consists of half isotonic saline (0.45%, or 77 mmol/L sodium), to which 75 mmol/L of sodium bicarbonate is added. Once overt renal failure has developed, the only reliable therapeutic modality is extracorporeal blood purification.4 Exchange transfusion or plasmaphresis has been found useful because it acts through a direct effect of reduction of the massive circulating venom or removal of the circulating mediators of inflammation caused by the venom itself.3,6 1.   Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med 1999; 170: 223-227. 3.   Bresolin NL, Carvalho LC, Goes EC, Fernandes R, Barotto AM. Acute renal failure following massive attack by Africanized bee stings. Pediatr Nephrol 2002; 17: 625-627. 5.   Schumacher MJ, Schmidt JO, Egen NB. Lethality of “killer” bee stings. Nature 1989; 337: 413. 2026 Ibrahim Medical College. All rights reserved.