Bees and wasps (order Hymenoptera) are commonly encountered worldwide and often deliver defensive stings when in contact with humans. Massive envenomation resulting from >50 stings causes a toxic reaction and life-threatening complications that typically result in rhabdomyolysis and disseminated intravascular coagulation. Two male patients who were stung over 80 times by wasps experienced severe coagulation abnormality. Consecutive examination by thromboelastography (TEG) guided by heparinase treatment during their hospitalization evidenced heparin-like coagulation dysfunction despite no clinical use of heparin-like substances. Numerous tests were also conducted to confirm whether the coagulation abnormalities could be attributed to hyperendogenous heparinization and allergic reaction, rhabdomyolysis, and vascular endothelial cell injury without apparent disseminated intravascular coagulation, which might all be affected by the production of endogenous heparin. The reduced coagulation potential caused by hyperendogenous heparinization was associated with the binding of antithrombin and the activation of fibrinolysis. In addition, TEG-identified coagulopathy was moderated using protamine for heparin neutralization. The massively envenomed patients survived and were discharged after completion of medical care. We also review clinical manifestations from other published case reports, including topical treatment. Our study provides clinical evidence and guidance for diagnosis via TEG and appropriate intervention with protamine for patients with massive wasp envenomation.
Background Postpartum hemorrhage (PPH) is a leading cause of severe maternal morbidity and mortality worldwide which leads to massive blood loss. Coagulation abnormalities in response to severe trauma or infection are a latent cause that might aggravate PPH. Case presentation: A 39-week menolipsis of a 26-year-old puerpera appeared lacking amniotic fluid and uterine infection after examination. During the cesarean section, the patient manifested fever, massive hemorrhage, and shock. The low coagulation of the PPH patient was diagnosed by thromboelastography (TEG) guided with heparinase (type I). According to the sequential monitoring via the TEG guided assay, the coagulopathy and hyper-heparinization were obviously shown. Concurrent protamine correction for the patient’s coagulation abnormality gradually resulted in a stable condition after 4 hours of emergent treatment. This setting revealed that TEG-guided determination of endogenous heparin and subsequent infusion of protamine effectively reversed the syndrome of PPH. Conclusions This is an investigation of the PPH syndrome with infection patient recommends that hyper-endogenous heparinization should be clinically taken into consideration for low coagulation.
Two over 80 wasp stings male victims appeared severe abnormal coagulation were consecutively examined by thromboelastography (TEG) guided with heparinase during hospitalization. However, the cause of coagulopathy remains unsolved. Rats were applied to establish a wasp-stung animal model highly resembled the manifestations of wasp-stung patients. According body surface area conversion, Sprague-Dawley rats were stung based on wasp sting numbers (0, 4, 8, 12 stings; n = 6 each) with various exposure times (0, 1, 3, 6 h) to determine the simulation of coagulopathy. The blood R, K values, and angle degree of wasp-stung rats were measured by TEG. The TEG profiles of stung rats were found to be concomitant with that of wasp-stung patients. Data showed that the endogenous heparinization of rats was time-dependent. Compared to the TEG profile of eight stings given rat, the coagulation time of 2 mm clot formation at 3 h (R value) was longer than that at 0 h. The coagulation time was prolonged with increasing sting numbers when compared to the various stings at 1, 3, and 6 h exposed. Interestingly, there was observed the peak coagulation at 3 h of eight stings. The Ck-standard and Ck-heparinase at 3 h after 8 stings given were R: 9.6–4.4 min; K: 3.8–1.8 min; angle degree: 49.8–68.0, respectively. The original data of R, K values and angle degree in two wasp-stung victims were 11.7–13.6 min, 4.3–5.5 min, and 41.2-32.8° in CK-standard, respectively; whereas those of the CK-heparinase groups were 5.6–6.7 min, 2.4–2.5 min, and 59.5–58.8°, correspondingly. Conclusively, this massive wasp-stung animal model can be applied to the investigations of pathogenesis and provides a clinical strategy or guideline for clinical intervention.
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