Hyperendogenous Heparinization Suggests a Guideline for the Management of Massive Wasp Stings in Two Victims

Abstract

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.

Wasp-stung rat model translationally expresses the coagulopathy manifestations of human wasp patients

“…This resulting hyper-endogenous heparinization is considered to be the vital reason for the coagulation dysfunction. 17 This “heparinization” would be explained by the anti-Xa activity that is attributed to the prolonged APTT detected in our patients. Secondly, we noted an extremely low fibrinogen level in the presence of normal platelet count and only a slight increase of D-dimers (absence of DIC).…”

“…Based on the heparinase-coated thromboelastography (TEG) test results, the coagulopathy of multiple wasp-stung patients was observed to be induced by endogenous heparin effect. 17 The coagulopathy is a clinical symptom and a critical risk factor for the management of massive wasp stings, but the relevance between coagulation abnormality and wasp envenomation remains unclear. 10,18 In this study, rats were given various numbers of wasp stings to highly resemble the coagulopathy phenomenon of human mass wasp envenomation as a rodent model, particular in the analysis of the alterations of endogenous heparinization.…”

Clinical manifestations of wasp stings: a case report and a review of literature

“…This phenomenon was named endogenous hyper-heparinization. This theory was further strengthened with the partial reversal of coagulopathy in thromboelastographic studies when protamine sulphate or heparinases were used [70]. The coagulopathy seemed to correlate with the wasp venom dose [27].…”

Anticoagulant properties and therapeutic potentials of wasp venom

“…Expanding on this concept, Lai et al (2021) reported two males who, after being stung over 80 times by wasps, exhibited severe coagulation abnormalities without evident DIC, and this condition was termed hyperendogenous heparinization. Treatment with heparinase and protamine as heparin neutralizers effectively managed coagulopathy, leading to recovery and discharge from the hospital (Lai et al 2021).…”

“…Treatment with heparinase and protamine as heparin neutralizers effectively managed coagulopathy, leading to recovery and discharge from the hospital (Lai et al . 2021).…”