Wasp venom and acute kidney injury: The mechanisms and therapeutic role of renal replacement therapy.

Stinging accidents involving wasp venom are a notable cause of acute kidney injury (AKI) in Asia. However, very little attention has been paid to the understanding of the mechanisms involved in this type of AKI. The aims of this review are to explore the evidence for the mechanisms and the therapeutic role of renal replacement therapy of wasp venom and AKI. A systematic literature search was conducted using PubMed for the association among wasp venom and AKI. Wasp venom is a complex mixture of biologically active components, including enzymes, amines, and peptides. Wasp venom may induce local anaphylaxis reactions as well as systemic reactions such as AKI. AKI may develop as a result of direct nephrotoxic effects of the venom or secondary intravascular hemolysis and/or rhabdomyolysis. Histopathological features of renal biopsies predominantly include acute tubular necrosis and acute interstitial nephritis. Renal replacement therapy, which includes intermittent hemodialysis, hemoperfusion, plasmapheresis, continuous renal replacement therapy, and peritoneal dialysis, has been used to treat severe AKI cases induced by wasp stings. Continuous renal replacement therapy appears to provide more benefit than intermittent hemodialysis in the treatment of wasp sting-induced AKI. In this review, we summarize the existing evidence of the mechanisms and treatment for venom-induced AKI, with a particular emphasis on the role of renal replacement therapy in the management of severe AKI following massive wasp stings.

Acute renal failure following multiple wasp stings.

Wasp bite induced ATN from direct venom toxicity is very rare. We report two such cases. The first case was a 14 years old boy admitted with oliguria following multiple wasp stings. He had grossly deranged renal function requiring hemodialysis support. The other patient was a 24 years old man admitted with similar history and also required hemodialysis support. Renal biopsy in both cases was consistent with acute tubular necrosis without any casts or other changes, suggesting direct venom toxicity. Both the patients recovered completely after a period of few weeks, highlighting the importance of early detection and treatment of renal failure from wasp venom.

Acute renal failure following wasp sting.

Wasp stings can result in multi system involvement ranging from intravascular hemolysis, rhabdomyolysis, acute renal failure cardiac involvement, hepatic dysfunction and occasionally thrombocytopenia and coagulopathy. We report here a case of eight year old boy presented with history of wasp sting followed by scanty micturation, generalized swelling and respiratory distress. After admission renal replacement therapy along with oral Prednisolone was started as serum creatinine level was gradually increasing. Kidney biopsy reveled Acute Interstitial Nephritis (AIN). Diagnosis was made of acute renal failure due to AIN following wasp stings.

Acute kidney injury due to acute cortical necrosis following a single wasp sting.

Acute kidney injury (AKI) can develop after multiple wasp or bee stings. The etiology is the acute tubular necrosis secondary to shock, pigment toxicity, interstitial nephritis, or direct nephrotoxicity of venom. We report a 40-year-old female who presented with oliguric AKI after a single wasp sting on her hand. Her history, examination, and investigations did not support any of the established causes of AKI in such settings. She did not improve with supportive management and dialysis, and kidney biopsy showed acute cortical necrosis (ACN). This is the first report of ACN after a single wasp sting.

Bilateral ptosis in a child following massive attack by a swarm of wasps.

Neurological manifestations of wasp sting are rare and the etiopathogenesis is not completely understood. We report a 2-year-old girl who developed bilateral ptosis after multiple wasp stings, which responded partially to pyridostigmine. This is the first reported case of wasp venom-induced ptosis in a child. We discuss the possible pathogenetic mechanisms behind this phenomenon.

[Venom immunotherapy. Side effects and efficacy of treatment]. / Insektengifthyposensibilisierung. Nebenwirkungen und Therapieerfolg.

Venom immunotherapy (VIT) protects patients with Hymenoptera venom anaphylaxis from subsequent potentially life-threatening reactions. The most important side effect are systemic anaphylactic reactions (SAR). Compared to the administration of aqueous extracts according to a rush protocol, the frequency of systemic and also local side effects will be lower if depot extracts are used and a slow conventional dose schedule is used, as compared to rush desensitization with aqueous extracts. However, protection often has to be achieved rapidly, and adequate surveillance of sufficient duration is hardly feasible in outpatients. Therefore, VIT according to rush schedules in inpatients remains indispensable. Pre-treatment with H(1)-blocking antihistamines reduces frequency and intensity of local and mild systemic adverse reactions during VIT. Up to 25% of patients again develop a SAR when re-stung while on VIT with the usual maintenance dose of 100 microg venom. Patients with honeybee venom allergy or with mastocytosis are at a higher risk for treatment failure. Almost all of them will become fully protected by increasing the maintenance dose, 200 microg venom being sufficient in most cases. Patients with significant risk factors may be treated from the beginning with an elevated maintenance dose, particularly when they are allergic to honeybee venom.

[Bionomics and defensive behaviour of bees and diplopterous wasps (Hymenoptera, Apidae, Vespidae) causing venom allergies in Germany]. / Bionomie und Abwehrverhalten der in Deutschland vorkommenden allergologisch bedeutsamen Bienen und Faltenwespen: (Hymenoptera, Apidae, Vespidae).

About 30 species of eusocial Apinae and 11 species of eusocial Polistinae and Vespinae are possible inducers of venom allergies in Germany. Twenty-three of these species occur regularly or occasionally in residential or recreational areas. Geographical and altitudinal distribution, phenology, nest sites and foraging habitats of these species are concisely characterized. Their defensive behavior is described.

[Hymenoptera venom anaphylaxis and cardiovascular disease]. / Hymenopterengiftanaphylaxie und Herz-Kreislauf-Erkrankungen.

Preexisting cardiovascular disease may worsen the course of anaphylaxis. This is illustrated based on the example of Hymenoptera venom allergy. Fatal sting anaphylaxis is most often observed in elderly patients. During autopsy preexisting cardiovascular disease is frequently found. Preexisting cardiovascular disease in patients with anaphylaxis may also cause lasting morbidity, e.g. cerebral or myocardial infarction. Heart medications, notably beta-blockers und ACE-inhibitors may worsen the course of anaphylactic reactions due to their pharmacologic effects. Since cardiovascular diseases are much more frequent than anaphylaxis and these medications are very effective, these drugs cannot be substituted in patients with both diseases without a careful risk analysis. Epinephrine is the drug of first choice for treatment of anaphylaxis. It may however, especially following rapid intravenous administration, cause severe arrhythmias or myocardial infarction. Adrenaline should therefore preferably be given intramuscularly, or by slow intravenous infusion.

Hypersensitivity to Vespula and Polistes: can we tell the primary sensitization from the clinical history? / Hipersensibilidad a vespula y polistes: ¿se puede determinar la sensibilización predominante a partir de la historia clínica?

Objective: To study the relationship between theprimary sensitization to wasp venoms and the geographicaland seasonal circumstances of the anaphylaxis-induced sting.Methods: We performed a retrospective review of115 patients (age 10-80) who suffered a systemicreaction to a wasp sting. Season and type of locality(urban or rural) at the moment of the sting wererecorded. Serum specific IgE levels to venoms fromVespula and Polistes were measured, and a primarysensitization was determined to whichever genus ofwasp for which the highest class of specific IgE wasobserved. The primary sensitization in relation to thetype of locality and the season was assessed usingthe chi-square test.Results: Most reactions occurred in urban areas(67.8 %), and in the summer season (63.4 %). Mostpatients were sensitized to Vespula venom (94.8 %).Primary sensitization was to Vespula in 56.5 %, toPolistes in 10.4 %, and undetermined in 33 %. Thedistribution of geographical areas did not show significantdifferences in relation to primary sensitization(p > 0.05). Most patients with primary sensitization toVespula suffered the anaphylaxis-induced sting afterthe spring season, with a statistically significant result(p < 0.05).Conclusion: In our population, the probability ofVespula sting is higher than Polistes sting when thereaction occurs after spring. This finding can help usto identify the responsible vespid when the diagnostictests do not provide an accurate result

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Hymenopterid bites, stings, allergic reactions, and the impact of hurricanes on hymenopterid-inflicted injuries.

Hymenopterid stings and subsequent allergic reactions are a common indication for emergency department visits worldwide. Unrecognized anaphylactic reactions to hymenopterid stings by apids, or bees, and vespids, or wasps, are a significant cause of sudden and unanticipated deaths outdoors in young people, with and without atopic histories. Insect bites and stings, often complicated by allergic reactions or skin infections, by community-acquired pathogens, such as methicillin-resistant Staphylococcus aureus, are common sources of morbidity following hurricanes, tropical storms, and prolonged flooding. This article will review and critically analyze the descriptive epidemiology and outcomes of hymenopterid bites, stings, and allergic reactions, especially following hurricanes and prolonged flooding disasters; stratify the immunologic reactions to hymenopterid stings by clinical severity and outcomes; and present current recommendations for management, prophylaxis, and prevention of hymenopterid stings and reactions.

[Hymenoptera stings]. / Ukaszenia przez blonkówki (Hymenoptera).

Hymenoptera are the large group of insects which includes honey-bees, bumble-bees, paper wasps, hornets, ants. Female hymenoptera possess specialized stinging apparatus with which they inject their venom into prey's or intruder's body. It could be life-threatening for people sensitive to the venom. The hymenoptera venom consists of mixture of biologically active substances, eg. enzymes (phospholipases, hialuronidase), peptides (melittin, apamin, mastoparans, bombolitins) and low-molecular-weight compounds (biogenic amines, acetylcholine, carbohydrates, lipids, free amino acids). Several types of reactions are possible to develop after stinging by hymenopteran insects: (1) non-allergic local reaction (pain, small oedema, redness at the site of the sting); allergic reactions: (2) large local reaction (extensive local swelling, exceeding 10 cm, persisting longer than 24 hours) and (3) anaphylaxis (generalized urticaria, bronchospasm, hypotension, cardiovascular collapse, loss of consciousness); (4) systemic toxic reaction (oedema, vomits, diarrhoea, headache, hypotension, seizures, altered mental status); (5) unusual reactions (cardiac ischaemia, encephalomyelitis et al.). Therapeutic management after stings includes removing of the stinger (bee stings), local remedies (ice-packs, topical steroids) and prevention and treatment of an anaphylactic shock (epinephrine, general steroids, beta-mimetics, fluid resuscitation, oxygen therapy). In the present review types of reaction after hymenoptera stings were described with special interest of anaphylactic and toxic reactions as well as therapeutic management after stings.

Multiple organ dysfunction syndrome following single wasp sting.

Wasp stings have been associated with wide variety of reactions from mild local reaction like wheal formation to fatal systemic reactions. Life threatening complications following a single wasp sting are relatively rare and unexpected. We report here the clinical course of a 12 year old child who developed Multiple Organ Dysfunction Syndrome (MODS) and died after a single wasp sting.

Hymenoptera stings.

The medically important groups of Hymenoptera are the Apoidea (bees), Vespoidea (wasps, hornets, and yellow jackets), and Formicidae (ants). These insects deliver their venom by stinging their victims. Bees lose their barbed stinger after stinging and die. Wasps, hornets, and yellow jackets can sting multiple times. Most deaths related to Hymenoptera stings are the result of immediate hypersensitivity reactions, causing anaphylaxis. Massive envenomations can cause death in nonallergic individuals. The estimated lethal dose is approximately 20 stings/kg in most mammals. Anaphylactic reactions to Hymenoptera stings are not dose dependent or related to the number of stings. Bee and wasp venoms are made up primarily of protein. Conversely, fire ant venoms are 95% alkaloids. Four possible reactions are seen after insect stings: local reactions, regional reactions, systemic anaphylactic responses, and less commonly, delayed-type hypersensitivity. Clinical signs of bee and wasp stings include erythema, edema, and pain at the sting site. Occasionally, animals develop regional reactions. Onset of life-threatening, anaphylactic signs typically occur within 10 minutes of the sting. Diagnosis of bee and wasp stings stem from a history of potential contact matched with onset of appropriate clinical signs. Treatment of uncomplicated envenomations (stings) consists of conservative therapy (antihistamines, ice or cool compresses, topical lidocaine, or corticosteroid lotions). Prompt recognition and initiation of treatment is critical in successful management of anaphylactic reactions to hymenopteran stings. Imported fire ants both bite and sting, and envenomation only occurs through the sting. Anaphylaxis after imported fire ant stings is treated similarly to anaphylactic reactions after honeybee and vespid stings. The majority of Hymenopteran stings are self-limiting events, which resolve in a few hours without treatment. Because life-threatening anaphylactic reactions can progress rapidly, all animals stung should be closely monitored and observed. In the following review article, we will examine the sources and incidence, toxicokinetics, pathological lesions, clinical signs, diagnosis, treatment, and prognosis for dogs and cats suffering Hymenoptera stings.

Epidemiological review of insect sting allergy in naval aviation: current policy and real-world practices.

Individuals with conditions not addressed in the physical standards section of the Navy's Manual of the Medical Department can be considered for a waiver that would allow them to continue in naval aviation. Insect sting allergy is addressed in the Navy's waiver guide; however, the actual disposition of these individuals does not coincide with published waiver policies. Our objective was to identify discrepancies, to review current clinical guidelines, and to offer recommendations for updating the Navy's waiver policy. Aviation medical records of individuals with insect sting allergies from 1985 to 2002 were reviewed. Disposition, waiver status, and allergy evaluation were investigated. The data suggest that waiver requests have been addressed not under the current waiver guidelines but instead under current clinical guidelines. New guidelines that properly reflect current diagnostic and treatment modalities were voted on by the Aeromedical Advisory Council and submitted to the Navy's Bureau of Medicine. These changes were incorporated into the Navy's aviation waiver policy guidelines.

Hornet sting induced systemic allergic reaction and large local reaction with bulle formation and rhabdomyolysis.

A 41-yr-old, previously healthy male was stung once by a hornet. The patient had no history of allergy or hornet stings. Physical examination revealed swelling of the right side of his body with blister formation on the extremities. Rhabdomyolysis developed. Treatment included corticosteroids, antihistamines, and cyproheptadine. The patient was discharged without sequellae after being hospitalized for 7 days.