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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 6  |  Page : 216-218

Acute kidney injury following multiple wasp stings: A case report


Department of Paediatrics, SVPPGIP, SCB Medical College, Cuttack, Odisha, India

Date of Submission18-Jul-2022
Date of Decision21-Aug-2022
Date of Acceptance23-Sep-2022
Date of Web Publication22-Nov-2022

Correspondence Address:
Dr. Bijay Kumar Meher
455/C, Sector 6, CDA, Cuttack - 753 014, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_62_22

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  Abstract 


Wasp and bees are venomous arthropods belonging to the order Hymenoptera, group Vespoidea. Most wasp sting victims do not seek medical attention due to the minor self-limiting and localizing nature of symptoms. Fatal anaphylaxis is rare. However, it is a common indication for emergency room visit. Acute kidney injury is the most serious complication with a mortality rate of 20%. Herein, we report the case of a 3-year 4-month-old female child, who presented with acute renal failure, after being stung by a swarm of wasps. She was managed successfully in the intensive care unit with renal replacement therapy.

Keywords: Acute kidney injury, envenomation, wasp sting


How to cite this article:
Meher BK, Pati SS, Panda I, Naik S. Acute kidney injury following multiple wasp stings: A case report. J Pediatr Crit Care 2022;9:216-8

How to cite this URL:
Meher BK, Pati SS, Panda I, Naik S. Acute kidney injury following multiple wasp stings: A case report. J Pediatr Crit Care [serial online] 2022 [cited 2022 Dec 8];9:216-8. Available from: http://www.jpcc.org.in/text.asp?2022/9/6/216/361677




  Introduction Top


Hymenoptera is an important cause of stings and bites in humans and is responsible for 50% of deaths from venomous stings and bites.[1] The medically important groups of Hymenoptera are the Apoidea (bees), Vespoidea (wasps, hornets, and yellow jackets), and Formicidae (ants). Fatal anaphylaxis by insect stings is a common indication for emergency department visits worldwide, with an estimated incidence of 0.3%–3% in the general population.[2] Multiple stings with a swarm of wasps, bees, or yellow jackets may cause serious local and systemic reactions including acute renal failure and multiorgan dysfunction.[3],[4],[5],[6] Herein, we describe a case of a 3-year 4-month-old female child, who presented with oliguria and features of fluid overload within 24 h of multiple wasp stings. She was managed successfully in the intensive care unit with close vital monitoring and renal replacement therapy (RRT).


  Case Report Top


A swarm of wasps attacked a 3-year 4-month-old female child and her mother while playing. Both were admitted to the nearby hospital for multiple envenomation. The child developed fever, decreased urination, and smoky-colored urine on the same day and was referred to our hospital 24 h post sting. On presentation, the child was irritable, sick looking, febrile, tachypneic (respiratory rate 34/min), pulse rate 120/min, good central and peripheral pulses, blood pressure 112/70 mmHg (95th to 95th +12 mmHg), and SpO2 95% in room air. There were facial puffiness, bilateral pitting pedal edema, and multiple bite marks; >25 stings over hands, legs, and face and some of which were pustules [Figure 1]. Abdominal examination revealed tenderness in the right hypochondrium without any signs of free fluid in the abdomen.
Figure 1: Photograph of the child showing multiple wasp stings undergoing peritoneal dialysis

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The child was admitted to the pediatric intensive care unit and started on injectable antibiotics and injection pheniramine, and monitored with intake-output charting. A fluid challenge test was done with normal saline of 20 ml/kg followed by an injection of furosemide. Oliguria was documented with urine output of 0.4 ml/kg/h, and therefore, fluid was started as per the AKI regimen (insensible fluid losses + urine output). Immediate laboratory results revealed lymphocytic leukocytosis (hemoglobin (Hb) - 13.8 g%, total lymphocyte count - 27,200/mm3, and L - 54.7%), raised C-reactive protein (CRP 8.19 mg/dl), raised blood urea nitrogen (BUN) (serum urea 53.7 mg/dl, creatinine 1.38 mg/dl), hyponatremia (Na+ 130.2 mmol/l) and hypokalemia (K+ 3.14 mmol/l), and compensated metabolic acidosis (pH 7.3, PCO2 16.6, HCO3 8). Oliguria persisted on the subsequent day with a calculated estimated glomerular filtration rate of <10 ml/min/1.73 m2 (modified Schwartz formula). Repeat laboratory results showed rising BUN (serum urea 166.5 mg% and creatinine 5.87 mg%), low albumin (2.51 g%), raised transaminases (serum glutamic pyruvic transaminase [SGPT] 753.9 IU/L and serum glutamic-oxaloacetic transaminase [SGOT] 1538 IU/L), and hyponatremia (Na+ 128 mmol/l) and hyperkalemia (K+ 6.2 mmol/L). However, there was no evidence of hemolysis (no drop in Hb, normal lactate dehydrogenase, and reticulocyte count), hemoglobinuria (urine microscopy negative for Hb), myoglobinuria (normal creatine phosphokinase and urine microscopy negative for myoglobin), or coagulopathy (normal prothrombin and partial thromboplastin time). Ultrasound kidney ureter bladder (KUB) revealed increased cortical echogenicity and prominent pyramids with normal kidney size. She was treated with tablet amlodipine for hypertension, which was eventually controlled. Acute peritoneal dialysis was started on day 3 of admission using infraumbilical approach and was continued for 72 h.

On day 6 of admission, the child improved hemodynamically with better sensorium and biochemical parameters were in improving trend (serum urea 124 mg/dl, serum creatinine 4.2 mg/dl, serum Na+ 137.5 mmol/L, and K+ 4.04 mmol/L). However, in view of persisting oliguria, hemodialysis was started. After two cycles of hemodialysis on alternate days, the patient's urine output improved with normal BUN (33 mg%) and creatinine (0.9 mg%) by day 15 of admission. She was discharged on day 22 on tablet amlodipine. At the 4-week follow-up, the skin lesions were healed. The child had normal renal function tests and serum electrolytes with normal blood pressure. Hence, the tablet amlodipine was discontinued.


  Discussion Top


Isolated hymenopteran stings usually occur when the insects are disturbed while searching for food. Wasps sting in defense, when they are accidentally stepped on, swatted, or otherwise disturbed. In contrast, mass envenomation occurs when stinging insects attack a human deemed as a threat to their colony, where hundreds of insects may be involved. In our case, multiple wasps attacked the child while she was playing near a wasp colony. Clinical manifestations following wasp sting vary from minor local reactions (edema, urticaria, erythema and localized pain) to fatal anaphylaxis. About 500 stings may be fatal to an adult due to direct toxicity. However, in children, as few as 30–50 stings may be fatal.[3] Our patient had around 25 sting marks all over her body. Few case reports of acute renal failure in children following multiple wasps and yellow jacket stings have been reported from India.[4],[5],[6]

Wasp venom contains various biogenic substances, such as toxic surface-active polypeptides (melittin and apamin), enzymes (phospholipase A2 and hyaluronidase), and low-molecular-weight agents (histamine and amino acids). Melittin and phospholipase cause rhabdomyolysis and hemolysis.[7] AKI results from a toxic-ischemic mechanism. Pathogenesis of AKI includes intralobular cast formation, pigment nephropathy due to direct toxic effects of myoglobulin on tubular epithelial cells, intrarenal vasoconstriction and ischemia due to inhibition of nitric oxide bioactivity by myoglobulin, and acute interstitial nephritis due to direct venom effect.[8].Other serious complications such as intravascular hemolysis, rhabdomyolysis, thrombocytopenia, liver function impairment, and myocardial infarction are less common but life-threatening.[9] Our patient had features of acute kidney injury without evidence of intravascular hemolysis or rhabdomyolysis, similar to a case reported by Vikrant et al. from India.[6] Most reported cases of acute renal failure secondary to multiple wasp stings had concomitant features of intravascular hemolysis or rhabdomyolysis.[4],[5],[6] Direct toxin-mediated hepatic damage has been reported by several authors and our case also had raised transaminases (SGOT and SGPT) suggestive of liver injury.[4],[6] Immediate management of anaphylaxis constitutes injectable antihistaminics, steroids, and epinephrine, with other supportive management as specific antivenom is not available.[9] Recognition of toxin-related complications with close monitoring is important. The primary therapeutic goal in such cases is to prevent volume depletion, tubular obstruction, and aciduria. Copious saline hydration and NaHCO3 for urine alkalization should be administered. Once overt renal failure develops, the only treatment option is dialysis.[10]

Multiple hymenoptera envenomation is a serious condition and children are particularly at high risk of developing multisystemic involvement and death. Early recognition of complications with intensive care monitoring and RRT are of paramount importance. The prognosis of the patient largely depends on the time interval between the sting and hospital admission.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardian has given their consent for child's images and other clinical information to be reported in the journal. The guardian understands that child's name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank Dr. Subal Pradhan for his help in managing the case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Seeyave DM, Brown KM. Environmental emergencies, radiological emergencies, bites and stings. In: Shaw KN, editor. Textbook of Pediatric Emergency Medicine. 7th ed. Philadelphia: Wolters Kluwer; 2016. p. 749-50.  Back to cited text no. 1
    
2.
Reisman RE. Insect stings. N Engl J Med 1994;331:523-7.  Back to cited text no. 2
    
3.
Bresolin NL, Carvalho LC, Goes EC, Fernandes R, Barotto AM. Acute renal failure following massive attack by Africanized bee stings. Pediatr Nephrol 2002;17:625-7.  Back to cited text no. 3
    
4.
Pramanik S, Banerjee S. Wasp stings with multisystem dysfunction. Indian Pediatr 2007;44:788-90.  Back to cited text no. 4
    
5.
Subramanian C, Jain V, Singh M, Kumar L. Allergic and systemic reactions following yellow jacket stings. Indian Pediatr 2000;37:1003-5.  Back to cited text no. 5
    
6.
Vikrant S, Pandey D, Machhan P, Gupta D, Kaushal SS, Grover N. Wasp envenomation-induced acute renal failure: A report of three cases. Nephrology (Carlton) 2005;10:548-52.  Back to cited text no. 6
    
7.
Mejía Vélez G. Acute renal failure due to multiple stings by Africanized bees. Report on 43 cases. Nefrologia 2010;30:531-8.  Back to cited text no. 7
    
8.
Nace L, Bauer P, Lelarge P, Bollaert PE, Larcan A, Lambert H. Multiple European wasp stings and acute renal failure. Nephron 1992;61:477.  Back to cited text no. 8
    
9.
Neuman MG, Eshchar J, Cotariu D, Ishay JS, Bar-Nea L. Hepatotoxicity of hornet's venom sac extract, after repeated in vivo and in vitro envenomation. Acta Pharmacol Toxicol (Copenh) 1983;53:314-9.  Back to cited text no. 9
    
10.
Paudel B, Paudel K. A study of wasp bites in a tertiary hospital of Western Nepal. Nepal Med Coll J 2009;11:52-6.  Back to cited text no. 10
    


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