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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 252-254

Rhabdomyolysis and acute kidney injury following multiple bee stings in a child: A case report


1 Department of Pediatrics, Baby Memorial Hospital, Kozhikode, Kerala, India
2 Department of Nephrology, Baby Memorial Hospital, Kozhikode, Kerala, India

Date of Submission18-Jun-2021
Date of Decision16-Aug-2021
Date of Acceptance26-Aug-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Abdul Rauf
Department of Pediatrics, Baby Memorial Hospital, Kozhikode - 673 004, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_38_21

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  Abstract 


Multiple bee stings commonly cause allergic and anaphylactic reactions, but it can also cause serious complications such as intravascular hemolysis, rhabdomyolysis, acute kidney injury (AKI), and even death. Mortality related to AKI following multiple bee stings can be as high as 25%. Hence, patients should be monitored for rhabdomyolysis and AKI during the first few days following the stings. We report the case of a 3-year-old boy who developed AKI due to rhabdomyolysis following multiple bee stings. He required pediatric intensive care support including mechanical ventilation and renal replacement therapy in the form of multiple sessions of hemodialysis. His renal function improved gradually. He was discharged after 3 weeks with normal renal function and he remained well on 6 months follow up. The treatment of multiple bee stings should be considered as a medical emergency, and these cases should be admitted in a pediatric intensive care unit and monitored for at least 48 h for the occurrence of rhabdomyolysis, myoglobinuria, and AKI.

Keywords: Acute kidney injury, children, multiple bee stings, rhabdomyolysis


How to cite this article:
Rauf A, Vijayan A, Hashitha V M, John ST, Peringat J. Rhabdomyolysis and acute kidney injury following multiple bee stings in a child: A case report. J Pediatr Crit Care 2021;8:252-4

How to cite this URL:
Rauf A, Vijayan A, Hashitha V M, John ST, Peringat J. Rhabdomyolysis and acute kidney injury following multiple bee stings in a child: A case report. J Pediatr Crit Care [serial online] 2021 [cited 2021 Oct 26];8:252-4. Available from: http://www.jpcc.org.in/text.asp?2021/8/5/252/326862




  Introduction Top


Bee stings are commonly reported in children, which may be single or multiple. Apart from the common issues such as allergic and anaphylactic reactions, it can also cause serious complications including rhabdomyolysis and hemolysis leading to acute kidney injury (AKI), particularly with multiple bee stings.[1] Nearly one-third of the cases of AKI following bee stings may require renal replacement therapy (RRT).[2] We report the case of a 3-year-old boy who developed AKI due to rhabdomyolysis and myoglobinuria following multiple bee stings.


  Case Report Top


A 3-year-old, previously well developmentally normal boy was stung by multiple bees, predominantly over the head and upper trunk, while he was playing outside his home. He was immediately taken to a local hospital, where he was treated with intravenous steroids and sent home after an observation period of 2 h, as he was asymptomatic. Few hours later, he developed multiple episodes of red-colored urine. Caregivers did not seek urgent medical attention, as they attributed it to the intravenous medication given. The next day morning, he developed alteration in sensorium in the form of drowsiness and was immediately taken to a local hospital, where he was found to be in hypotensive shock. He was treated as a case of anaphylactic shock with intramuscular adrenaline and fluid resuscitation and referred to our center.

At admission to the emergency department, he was in hypotensive shock and had respiratory distress. He had several bee sting marks over his head and upper trunk. He was stabilized and shifted to pediatric intensive care unit (ICU). The stingers present were removed. Therapeutic end points of shock were achieved with adrenaline infusion (0.1mcg/kg/min), respiratory distress improved with high-flow nasal cannula support (flow rate of 2 L/kg, 40% FiO2), and his sensorium also improved. His urinary bladder was catheterized and it drained red-colored urine. Initial investigations were suggestive of AKI (serum creatinine – 2.64 mg/dl), probably due to rhabdomyolysis with myoglobinuria, as evidenced by elevated serum Creatine phosphokinase (CPK) levels (81869 U/L) and urine myoglobin (3+). He was initially managed with intravenous hydration and urine alkalinization. In the first two days, he had normal sensorium and maintained good urine output with decreasing trend of serum CPK levels with a marginal increase in serum creatinine levels. On day 2, there was a sudden fall in hemoglobin level (from 15.6 to 7.7 g/dl), probably due to hemolysis (peripheral smear suggestive of hemolysis), and packed red blood cell transfusion was given.

On day 3, he showed clinical worsening in the form of increased drowsiness and examination showed brisk deep tendon reflexes. Laboratory parameters revealed rising values of serum urea and creatinine with increasing serum CPK levels, probably due to the ongoing rhabdomyolysis [Table 1]. As part of anti-raised intracranial pressure measures and due to the deteriorating sensorium, the child was intubated and mechanically ventilated with adequate sedation and initiated on other neuroprotective measures. RRT with hemodialysis–sustained low-efficiency dialysis (SLED) was initiated in view of the worsening AKI with uremic encephalopathy. Over the next 5 days, he was continued on mechanical ventilation and underwent daily sessions of SLED. His urine became clear gradually and serial serum creatinine and serum CPK levels showed decreasing trend [Table 1].
Table 1: Serial values of hemoglobin, renal function tests, creatinine phosphokinase, and liver enzymes of the child

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He was weaned off ventilator and extubated on day 9 of hospital stay. Subsequently, there was a steady clinical improvement over the next few days. AKI was further managed conservatively and serial serum creatinine values showed a decreasing trend. His urine output and metabolic parameters remained normal. He was shifted to room and discharged after 3 weeks of hospital stay. Serum creatinine value at discharge was normal for age (0.44 mg/dL). He was followed up periodically for 6 months in the outpatient department, during which his serum creatinine and urine routine analysis remained normal.


  Discussion Top


Bees belong to the arthropod order Hymenoptera, whose venom is, in general, well tolerated. Although in most cases, the sting causes only minor reactions such as erythema, edema, and local pain, it can also trigger immediate IgE-mediated allergic reactions such as urticaria, angioedema, and anaphylactic shock. In some cases, especially with multiple stings, unusual life-threatening complications such as intravenous hemolysis, rhabdomyolysis, AKI, hepatic injury, and myocardial infarction have been reported.[3] The complications and prognosis are worse with increasing number of stings because of the inoculation of a higher amount of venom. Mortality rates for AKI following multiple bee stings have been reported to be from 15% to 25% in previously published studies.[4],[5]

The main poisonous components in the bee venom are melittin, apamin, peptide 401, and phospholipase A2, with melittin being the lethal component. Multiple factors such as intravascular hemolysis, rhabdomyolysis, hypotension, and direct toxicity of the venom components to the renal tubules contribute to AKI following bee stings.[5],[6] In most of the cases, like in our case, the onset of AKI occurs 24–48 h after the stings.

The treatment of multiple bee stings should be considered a medical emergency. Initial steps of management include stabilization of vital parameters, removal of stingers, and treatment of anaphylaxis.[7] Our case emphasizes the point that these patients should be admitted and need to be monitored for at least 48 h for the occurrence of rhabdomyolysis, myoglobinuria, and AKI. Bladder catheterization is essential for close monitoring of urine color and urine output. Adequate intravenous hydration is necessary in cases of rhabdomyolysis. The management of AKI caused by bee stings is similar to AKI treatment due to any other etiology. Monitoring for the complications of AKI and good supportive care in pediatric ICU is of paramount importance. There is no consensus on the most effective mode of RRT for the treatment of AKI caused by bee stings. However, the effectiveness of hemodialysis in these contexts has been well reported. Sustained low-efficiency dialysis is increasingly used as a renal replacement modality in critically ill patients with AKI and hemodynamic instability as it reduces the hemodynamic adverse effects of intermittent hemodialysis, while obviating the resource demands of continuous RRT.[8] The duration of renal recovery in cases with AKI following bee stings requiring RRT is 3–6 weeks.[9] Renal function should be monitored long term in these cases as the condition may progress to chronic kidney disease.

The treatment of multiple bee stings should be considered as a medical emergency and monitored for at least 48 h for the occurrence of rhabdomyolysis, myoglobinuria, and AKI.

Acknowledgments

The authors acknowledge Dr. Yassar Andru, Dr. Sayid Sabik, and nursing staff in pediatric ICU for their involvement in patient care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Deshpande PR, Farooq AK, Bairy M, Prabhu RA. Acute renal failure and/or rhabdomyolysis due to multiple bee stings: A retrospective study. N Am J Med Sci 2013;5:235-9.  Back to cited text no. 1
    
2.
Vikrant S, Parashar A. Acute kidney injury due to multiple Hymenoptera stings-A clinicopathological study. Clin Kidney J 2017;10:532-8.  Back to cited text no. 2
    
3.
Mingomataj EÇ, Bakiri AH, Ibranji A, Sturm GJ. Unusual reactions to hymenoptera stings: What should we keep in mind? Clin Rev Allergy Immunol 2014;47:91-9.  Back to cited text no. 3
    
4.
Zhang L, Yang Y, Tang Y, Zhao Y, Cao Y, Su B, et al. Recovery from AKI following multiple wasp stings: A case series. Clin J Am Soc Nephrol 2013;8:1850-6.  Back to cited text no. 4
    
5.
Thiruventhiran T, Goh BL, Leong CL, Cheah PL, Looi LM, Tan SY. Acute renal failure following multiple wasp stings. Nephrol Dial Transplant 1999;14:214-7.  Back to cited text no. 5
    
6.
Grisotto LS, Mendes GE, Castro I, Baptista MA, Alves VA, Yu L, et al. Mechanisms of bee venom-induced acute renal failure. Toxicon 2006;48:44-54.  Back to cited text no. 6
    
7.
Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet 1996;348:301-2.  Back to cited text no. 7
    
8.
Kitchlu A, Adhikari N, Burns KE, Friedrich JO, Garg AX, Klein D, et al. Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: a cohort study. BMC Nephrol 2015;16:127.  Back to cited text no. 8
    
9.
Silva GB Junior, Vasconcelos AG Junior, Rocha AM, Vasconcelos VR, Barros J Neto, Fujishima JS, et al. Acute kidney injury complicating bee stings-A review. Rev Inst Med Trop Sao Paulo 2017;59:e25.  Back to cited text no. 9
    



 
 
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