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.
Similar content being viewed by others
References
Golden DB, Moffitt J, Nicklas RA, Joint Task Force on Practice Parameters; American Academy of Allergy, Asthma & Immunology (AAAAI); American College of Allergy, Asthma & Immunology (ACAAI); Joint Council of Allergy, Asthma and Immunology (2011) Stinging Insect Hypersensitivity: A Practice Parameter Update 2011. J Aller Clin Immunol 127:852–854, e1-23
Müller U (1989) Clinical Aspects, Diagnosis and Therapy of Insect Bite Allergy. Schweiz Med Wochenschr 119:1761–1768 [In German]
Biló, B. M., Rueff, F., Mosbech, H., Bonifazi, F., and Oude-Elberink, J. N. The EAACI Interest Group on Insect Venom Hypersensitivity* (2005) Diagnosis of Hymenoptera venom allergy. Allergy 60:1339–1349
Mingomataj E, Ohri D, Dhimitri V et al (2003) Hymenoptera Sting Anaphylactic Reactions in the Mediterranean Population of Albania. J Investig Allergol Clin Immunol 13:272–277
Reisman RE (2005) Unusual Reactions to Insect Stings. Curr Opin Allergy Clin Immunol 5:355–358
Reisman RE (1991) Unusual Reactions to Insect Venoms. Allergy Proc 6:395–399
Marichal T, Starkl P, Reber LL et al (2013) A Beneficial Role for Immunoglobulin E in Host Defense Against Honeybee Venom. Immunity 39:963–975
Cichocka-Jarosz E, Weglarz M, Romanowska-Dixon B (2009) Hymenoptera Stings in Eyeball—Clinical Symptoms, Patomechanism and Treatment. Klin Oczna 111:80–83 [In Polish]
Arcieri ES, Franca ET, de Oliveria HB, de Abreu Ferreira L, Ferreira MA, Rocha FJ (2002) Ocular Lesions Arising After Stings by Hymenopteran Insects. Cornea 21:328–330
Limaiem R, Chaabouni A, ElMaazi A, Mnasri H, Mghaieth F, ElMatri L (2009) Ocular Lesions After Bee Sting of the Cornea. a Case Report. J Fr Ophtalmol 32:277–279, In French
Chuah G, Law E, Chan WK, Ang CL (1996) Case Reports and Mini Review of Bee Stings of the Cornea. Singap Med J 37:389–391
Chen CJ, Richardson CD (1986) Bee Sting-induced Ocular Changes. Ann Ophthalmol 18:285–286
Smoley BA (2002) Oropharyngeal Hymenoptera Stings: a Special Concern for Airway Obstruction. Mil Med 167:161–163
Simons FER, Ardusso LRF, Dimov V et al (2013) World Allergy Organization Anaphylaxis Guidelines: 2013 Update of the Evidence Base. Int Arch Allergy Immunol 162:193–204
Sharmila RR, Chetan G, Narayanan P, Srinivasan S (2007) Multiple Organ Dysfunction Syndrome Following Single Wasp Sting. Indian J Pediatr 74:1111–1112
Candiotti KA, Lamas AM (1993) Adverse Neurologic Reactions to the Sting of the Imported Fire Ant. Int Arch Aller Immunol 102:417–420
Rubí-Callejón J, Arjona A, Serrano-Castro PJ, Alonso-Verdegay G, Huete-Hurtado A (2006) Acute Disseminated Encephalomyelitis due to Hymenoptera Stings. Rev Neurol 42:408–410 [In Spanish]
Temizoz O, Celik Y, Asil T, Balci K, Unlu E, Yilmaz A (2009) Stroke Due to Bee Sting. Neurologist 15:42–43
Taurin G, Canneva-Bourel ML, Delafosse JM, Poirier J, Merienne M (2006) Dorsal Medulla Oblongata Stroke After a Wasp Sting. Rev Neurol (Paris) 162:371–373 [In French]
Dikici S, Aydin LY, Saritas A, Kudas O, Kandis H (2012) An Unusual Presentation of Bee Sting: Subarachnoid Hemorrhagia. Am J Emerg Med 30:1663.e5–6
Kwon OY, Chung SP, Lee KR, Kim SW (2007) Spontaneous Subarachnoid Hemorrhage After Intravenous Epinephrine Use for Multiple Bee Stings. Am J Emerg Med 25:249–250
Remes-Troche JM, Téllez-Zenteno JF, Rojas-Serrano J, Senties-Madrid H, Vega-Boada F, García-Ramos G (2003) Thalamic and Mesencephalic Hemorrhages After Multiple Honeybee Stings: a Life-threatening Apitherapy Complication. Eur Neurol 49:188–189
Bhat R, Bhat KR, Shivashankar, Pais R (2002) Bilateral Haemorrhagic Cerebellar Infarction Following Honey Bee Sting. J Assoc Physicians India 50:721–722
Grotta JC (2006) Intracerebral Hemorrhage: Effective Therapy at Least? Int J Stroke 1:30–31
Bánovcin P, Havlíceková Z, Jesenák M et al (2009) Severe Quadriparesis Caused by Wasp Sting. Turk J Pediatr 51:485–488
Gomes JA, Stevens RD, Lewin JJ 3rd, Mirski MA, Bdardwaj A (2005) Glucocorticoid Therapy in Neurologic Critical Care. Crit Care Med 33:1214–1224
Mingomataj EÇ, Bakiri AH (2012) Episodic Hemorrhage During Honeybee Venom Anaphylaxis: Potential Mechanisms. J Invest Allergol Clin Immunol 22:237–244
Boz C, Velioglu S, Ozmenoglu M (2003) Acute Disseminated Encephalomyelitis After Bee Sting. Neurol Sci 23:313–315
Van Antwerpen CL, Gospe SM Jr, Wade NA (1988) Myeloradiculopathy Associated with Wasp Sting. Pediatr Neurol 4:379–380
Ridolo E, Albertini R, Borghi L, Meschi T, Montanari E, Dall’Aglio PP (2005) Acute Polyradiculoneuropathy Occurring After Hymenoptera Stings: a Clinical Case Study. Int J Immunopathol Pharmacol 18:385–390
Panagariya A, Sharma B, Garg A (2003) Oculopalatal Syndrome with Ataxia Following Hymenoptera Sting. J Assoc Physicians India 51:1007–1008
Kraker J, Zivković SA (2011) Autoimmune Neuromuscular Disorders. Curr Neuropharmacol 9:400–408
Korantzopoulos P, Kountouris E, Voukelatou M, Charaktsis I, Dimitroula V, Siogas K (2006) Acute Myocardial Infarction After a European Hornet Sting—a Case Report. Angiology 57:383–386
Cvetković-Matić D, Asanin M, Matić D et al (2009) Acute Myocardial Infarction Following a Hornet Sting. Vojnosanit Pregl 66:333–337
Mathew A, Chrispal A, David T (2011) Acute Myocardial Injury and Rhabdomyolysis Caused by Multiple Bee Stings. J Assoc Physic India 59:518–520
Lombardi A, Vandelli R, Cere E, Di Pasquale G (2003) Silent Acute Myocardial Infarction Following a Wasp Sting. Ital Heart J 4:638–641
Ceyhan C, Ercan E, Tekten T, Kirilmaz B, Onder R (2001) Myocardial Infarction Following a Bee Sting. Int J Cardiol 80:251–253
Wagdi P, Mehan VK, Burgi H, Salzmann C (1994) Acute Myocardial Infarction After Wasp Stings in a Patient with Normal Coronary Arteries. Am Heart J 128:820–823
Santhosh MSR, Viswanathan S, Kumar S (2012) The Bee Sting Related Wolff-Parkinson-White Syndrome. J Clin Diagn Res 6:1541–1543
Lam SM (1998) Acute pulmonary Hemorrhage Following a Honeybee Sting: a Case Report. J Microbiol Immunol Infect 31:133–136
Daisley H (1998) Acute Haemorrhagic Pancreatitis Following Multiple Stings by Africanized Bees in Trinidad. Trans R Soc Trop Med Hyg 92:71–72
Mukhopadhyay A, Fong KF, Lim TK (2002) Diffuse Alveolar Hemorrhage: a Rare Reaction to Insect Sting. Respirology 7:157–159
Ben-Shoshan M, Clarke AE (2011) Anaphylaxis: Past, Present and Future. Allergy 66:1–14
Nandi M, Sarkar S (2012) Acute Kidney Injury Following Multiple Wasp Stings. Pediatr Nephrol 27:2315–2317
MejíaVélez G (2010) Acute Renal Failure due to Multiple Stings by Africanized Bees. Report on 43 Cases. Nefrologia 30:531–538 [In Spanish]
Yanagawa Y, Morita K, Sugiura T, Okada Y (2007) Cutaneous Hemorrhage or Necrosis Findings After Vespa Mandarinia (Wasp) Stings may Predict the Occurrence of Multiple Organ Injury: a Case Report and Review of Literature. Clin Toxicol 45:803–807
Oliveira EC, Pedroso PM, Meirelles AE, Pescador CA, Gouvêa AS, Driemeier D (2007) Pathological Findings in Dogs After Multiple Africanized Bee Stings. Toxicon 49:1214–1218
Daher Ede F, da Silva Junior GB, Bezerra GP (2003) Acute Renal Failure After Massive Honeybee Stings. Rev Inst Med Trop Sao Paulo 45:45–50
Zhang R, Meleg-Smith S, Batuman V (2001) Acute Tubulointerstitial Nephritis after Wasp Stings. Am J Kidney Dis 38:E33
Chao YW, Yang AH, Ng YY, Yang WC (2004) Acute Interstitial Nephritis and Pigmented Tubulopathy in a Patient After Wasp Stings. Am J Kidney Dis 43:5–9
Chatzizisis YS, Misirli G, Hadzitolios AI, Giannoglou GD (2008) The Syndrome of Rhabdomyolysis: Complications and Treatment. Eur J Intern Med 19:568–574
Lin CC, Chang MY, Lin JL (2003) Hornet Sting Induced Systemic Allergic Reaction and Large Local Reaction with Bulle Formation and Rhabdomyolysis. J Toxicol Clin Toxicol 41:1009–1011
Sawyer JR, Kellum EL, Creek AT, Wood GW 3rd (2010) Acute Compartment Syndrome of the Hand After a Wasp Sting: a Case Report. J Pediatr Orthop B 19:82–85
Akbayram S, Akgun C, Dogan M, Caksen H, Oner AF (2011) Acute ITP due to Insect Bite: Report of 2 Cases. Clin Appl Thromb Hemost 17:408–409
Namdev R, Dutta SR, Singh H (2009) Acute Immune Thrombocytopenic Purpura Triggered by Insect Bite. J Ind Soc Pedod Prev Dent 27:58–61
Tanphaichitr VS, Tuchinda M (1982) Severe Thrombocytopenic Purpura Following a Bee Sting. Ann Allergy Asthma Immunol 49:229–231
Quercia O, Emiliani F, Foschi FG, Stefanini GF (2007) Unusual Reaction to Hymenoptera Sting: a Case of Schönlein-Henochpurpura. Allergy 62:333–334
Hermes B, Haas N, Grabbe J, Czarnetzki BM (1994) Foreign-body Granuloma and IgE-pseudolymphoma After Multiple Bee Stings. Br J Dermatol 130:780–784
Olivares-Becerra JJ, Cuan-Orozco F, Michel-Dueñas J, López-Ramírez MK, Velázquez-Ramírez GA, González-Ojeda A (2005) Splenic Abscess Secondary to Massive Bee Bite in Immunocompetent Host. a Case Report. Cir Cir 73:383–387 [In Spanish]
Koçer U, Ozer Tiftikcioğlu Y, Mete Aksoy H, Karaaslan O (2003) Skin and Soft Tissue Necrosis Following Hymenoptera Sting. J Cutan Med Surg 7:133–135
Ventura F, Gallo M, De Stefano F (2010) Postmortem Skin Damage due to Ants: Description of 3 Cases. Am J Forensic Med Pathol 31:120–121
Knight D, Bangs MJ (2007) Cutaneous Allergic Vasculitis due to Solenopsis Geminata (Hymenoptera: Formicidae) Envenomation in Indonesia. Southeast Asian J Trop Med Public Health 38:808–813
Petreniuk LM, Mikheeva AI, Golubeva AV (1979) Hemorrhagic Vasculitis in a Patient Stung by Bees. Ter Arkh 51:100–101 [In Russian]
Gädeke R, Helwig H, Otto M, Schindera F, Weineck B (1977) [Fatal Poison Disease of a Child Following Massive Wasp Stings (author’s Transl). Med Klin 72:1487–1492 [In German]
Cowell AK, Cowell RL, Tyler RD, Nieves MA (1991) Severe Systemic Reactions to Hymenoptera Stings in Three Dogs. J Am Vet Med Assoc 198:1014–1016
Hoffman DR, El-Choufani SE, Smith MM, de Groot H (2001) Occupational Allergy to Bumblebees: Allergens of Bombus Terrestris. J Allergy Clin Immunol 108:855–860
Seebach JD, Bucher C, Anliker M, Schmid-Grendelmeier P, Wüthrich B (2000) Ant Venoms: A Rare Cause of Allergic Reactions in Switzerland. Schweiz Med Wochenschr 130:1805–1813 [In German]
Fernández-Meléndez S, Miranda A, García-González JJ, Barber D, Lombardero M (2007) Anaphylaxis Caused by Imported red Fire ant Stings in Málaga Spain. J Invest Allergol Clin Immunol 17:48–49
Schumacher MJ, Egen NB (1995) Significance of Africanized Bees for Public Health A review. Arch Intern Med 155:2038–2043
Sandes RL Jr, Oliveira CL, Ferreira ES et al (2009) Spatial Analysis of Migrating Apis Mellifera Colonies in Salvador, Bahia Brazil. Geospat Health 4:129–134
Harrison JF, Fewell JH, Anderson KE, Loper GM (2006) Environmental Physiology of the Invasion of the Americas by Africanized Honeybees. Integr Comp Biol 46:1110–1122
Almeida RA, Olivo TE, Mendes RP et al (2011) Africanized Honeybee Stings: how to Treat Them. Rev Soc Bras Med Trop 44:755–761
West PL, McKeown NJ, Hendrickson RG (2011) Massive Hymenoptera Envenomation in a 3-Year-old. Pediatr Emerg Care 27:46–48
Stapel SO, Waanders-Lijster de Raadt J, van Toorenenbergen AW, de Groot H (1998) Allergy to Bumblebee Venom II IgE cross-reactivity between bumblebee and honeybee venom. Allergy 53:769–777
Sciani JM, Marques-Porto R, Lourenço Junior A et al (2010) Identification of a Novel Melittin Isoform from Africanized Apis mellifera Venom. Peptides 31:1473–1479
Golden DBK, Kagey-Sobotka A, Norman PS, Hamilton RG, Lihtenstein LM (2004) Outcomes of Allergy to Insect Stings in Children, With and Without Venom Immunotherapy. N Engl J Med 351:668–674
Golden DB (2005) Insect Sting Allergy and Venom Immunotherapy: A Model and a Mystery. J Allergy Clin Immunol 115:439–448
Mingomataj EÇ (2006) Favorable Hymenoptera Sting Reactions During Childhood may Have Enabled Transmission of Responsible Allergic Genotype into Generations. Med Hypotheses 67:327–332
Bonifazi F, Jutel M, Biló BM, Birnbaum J, Muller U (2005) EAACI Interest Group on Insect Venom Hypersensitivity: Prevention and Treatment of Hymenoptera Venom Allergy: Guidelines for Clinical Practice. Allergy 60:1459–1470
Peternelj A, Silar M, Erzen R, Kosnik M, Korosec P (2008) Basophil Sensitivity in Patients not Responding to Venom Immunotherapy. Int Arch Aller Immunol 146:248–254
Papadopoulos NG, Agache I, Bavbek S et al (2012) Research Needs in Allergy: An EAACI Position Paper, in Collaboration With EFA. Clin Transpl 2:21
Acknowledgment
Authors cordially thank Ms Maniela Sota for her kind support in copyediting this manuscript.
Conflict of Interest
Authors do not have any conflict of interest to declare.
Author information
Authors and Affiliations
Corresponding author
Additional information
We confirm that this manuscript is not published or addressed for publication elsewhere.
Rights and permissions
About this article
Cite this article
Mingomataj, E.Ç., Bakiri, A.H., Ibranji, A. et al. Unusual Reactions to Hymenoptera Stings: What Should we Keep in Mind?. Clinic Rev Allerg Immunol 47, 91–99 (2014). https://doi.org/10.1007/s12016-014-8434-y
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12016-014-8434-y