Unusual Reactions to Hymenoptera Stings: What Should we Keep in Mind?

Abstract

This review includes a variety of extremely rare and unusual hymenoptera sting (HS) circumstances with regard to sting localization, geographic region, massivity of multiple stings, and particularly related to clinical symptoms. Such reactions occur in a temporal relationship to HS (s), differ from typical allergic symptomatology, and sometimes need follow-up during many months. With respect to pathogenesis, the major mechanisms involved are toxic, autoimmune, and other delayed immunological ones. While delayed inflammatory symptoms of the nervous system are considered as delayed hypersensitization or autoimmune entities, generalized rhabdomyolysis and consecutive acute kidney injury is considered a toxic reaction, mostly induced by massive envenomation to wasps or "Africanized" bees. Hemorrhagic episodes of targeted organ (s) could be additional potential risk for acute kidney injury, while the bee venom-induced hemorrhage is proposed to be a nonimmune-mediated anaphylactic symptom. The hemodynamic involvement of vital organs and systems with hypoxia and hypovolemia together with simultaneous immunoglobulin E (IgE) sensitization are considered potential indications for venom immunotherapy. In contrast, patients who have experienced various complications with unknown or nonallergic mechanisms should be informed about the importance of epinephrine's use and additional measures on future sting avoidance. In conclusion, although unusual reactions are extremely rare, it is important to keep them in mind.

Acute kidney injury complicating bee stings – a review

“…Acute kidney injury can be observed in patients suffering from bee stings and this is due to multiple factors, such as intravascular hemolysis, rhabdomyolysis, hypotension, and direct toxicity of the venom components to the renal tubules 1,2 . Arterial hypotension plays an important role in this type of AKI, leading to ischemic renal lesion 10 .…”

“…Bee venom, which has as its main components hyaluronidase, phospholipase A2, melitin and apamin, contributes to renal damage due to synergistic toxic and hypotensive effects 1,11 . Moreover, these substances can induce the release of several other mediators, such as histamine, serotonin, bradykinin and prostaglandin.…”

“…Moreover, these substances can induce the release of several other mediators, such as histamine, serotonin, bradykinin and prostaglandin. These substances are vasoactive and may lead to a reduction in systemic blood pressure 1,12 . A reduction in the norepinephrine content was observed in rats inoculated with bee venom, suggesting a great release of this mediator 13 .…”

“…In most cases, the sting causes erythema, edema and local pain. However, the sting may trigger immediate allergic reactions mediated by immunoglobulin E (IgE), with urticaria, angioedema, respiratory symptoms (dyspnea or asthma) and cardiovascular symptoms (hypotension and anaphylactic shock) 1 .…”

“…Insect venom of the Hymenoptera order (bees and wasps) is responsible for 14% of the cases of anaphylactic reactions, constituting the second place among the causes, second only to food antigens (33 to 34%) 1 .…”