Multiple European wasp stings and acute renal failure

Unusual case of acute renal failure following multiple wasp stings

The wasp stings usually cause local reactions and rarely anaphylaxis. However the multiple wasp stings may cause multisystem involvement. We report a case of acute renal failure (ARF) following multiple wasp stings. A middle aged healthy gentleman presented with pain and swelling of the upper part of the body following multiple wasp stings. After 2 days, he developed progressive decrease in urine output with high colored urine. Physical examination revealed the edematous and tender affected part. On investigating, it was found to have sequential elevations in renal function tests. The markers of muscle injury were grossly elevated and liver enzymes were deranged. These findings suggest multisystem involvement predominantly ARF secondary to rhabdomyolysis. With the initiation of the intense hemodialysis, all the above parameters became normal. Timely intervention of multiple wasp stings causing ARF with multiorgan involvement by hemodialysis not only prevents mortality but also other complications.

Delayed onset interstitial nephritis following multiple wasp stings

A wasp sting rarely causes delayed / late onset hypersensitivity reaction. Although unknown, the mechanism of such a delayed hypersensitivity reaction is thought to be an immunologically mediated, type III hypersensitivity reaction with the deposition of immune complexes and activation of the complement system. We present here the case of a seven year-old girl with acute interstitial nephritis following multiple wasp stings. To the best of our knowledge, this is the first such report of delayed presentation in a child from India.

Acute renal failure following wasp sting in children

The medical records of patients admitted between 1985 and 2007 with wasp stings were retrospectively analyzed. Among the 45 children, seven developed acute renal failure. Classical clinical and laboratory data pointed to hemolysis and rhabdomyolysis as the underlying pathophysiology. All patients had hyponatremia and hyperkalemia as well as metabolic acidosis. Six patients had anemia. Five patients were oliguric for 9 to 15 days. Maximum serum creatinine was 4.0 to 11.9 mg/dl. Peritoneal dialysis was performed for 3 to 15 days. One patient died due to hyperkalemia, the remaining ones recovered completely. This paper wants to remind pediatricians to watch for acute renal failure in children with wasp stings.

Acute tubulo-interstitial nephritis leading to acute renal failure following multiple hornet stings

Background

Hornet stings are generally associated with local and occasionally anaphylactic reactions. Rarely systemic complications like acute renal failure can occur following multiple stings. Renal failure is usually due to development of acute tubular necrosis as a result of intravascular haemolysis, rhabdomyolysis or shock. Rarely it can be following development of acute tubulo-interstitial nephritis.

Case presentation

We describe a young male, who was stung on face, head, shoulders and upper limbs by multiple hornets (Vespa orientalis). He developed acute renal failure as a result of acute tubulo-interstitial nephritis and responded to steroids.

Conclusion

Rare causes of acute renal failure like tubulo-interstitial nephritis should be considered in a patient with persistent oliguria and azotemia following multiple hornet stings. Renal biopsy should be undertaken early, as institution of steroid therapy may help in recovery of renal function

Wasp envenomation-induced acute renal failure: a report of three cases

Acute renal failure is an unusual complication of wasp stings. We report three cases who developed acute renal failure after multiple wasp stings (Vespa magnifica). Two patients had evidence of intravascular haemolysis and rhabdomyolysis whereas one patient investigation showed no evidence of intravascular haemolysis or rhabdomyolysis. All three cases had impaired liver functions. Oligo-anuria was seen in all three of the patients and all of them required dialytic support. One patient died of massive gastrointestinal bleeding while the remaining two recovered completely. Although acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of haemolysis or rhabdomyolysis, in some patients, renal failure may result from a direct nephrotoxic effect or acute interstitial nephritis from a hypersensitivity reaction to the wasp venom.

Acute renal failure following multiple wasp stings

We report the cases of two patients who developed acute renal failure following multiple wasp stings. Both patients required dialysis and recovered within 4 weeks. The kidney biopsy from one patient showed acute tubular necrosis with interstitial nephritis. One patient had complete recovery of renal function on follow-up, while the other was lost to follow-up.

Acute interstitial nephritis and pigmented tubulopathy in a patient after wasp stings

Acute renal failure (ARF) is an unusual complication of wasp stings and mostly results from toxic-ischemic acute tubular necrosis. This patient, who was stung by a swarm of wasps, experienced an allergic reaction, rhabdomyolysis, intravascular hemolysis, and subsequent ARF. The originality of this case report is related to the finding of combined lesions of acute tubulointerstitial nephritis and acute tubular nephropathy. From our extensive literature review, it is the first case of a patient developing this type of injury after wasp stings, and the complications have been documented previously only in one form or another. Renal biopsy should be encouraged, especially for a patient with delayed recovery of renal function after wasp stings, to facilitate early steroid treatment for the patient with the histological change of acute interstitial nephritis. Early use of steroid therapy may hasten renal recovery by preventing the development of interstitial fibrosis.

Acute renal failure after massive honeybee stings

Two clinical cases of patients who survived after numerous attacks of Africanized bees (600 and 1500 bee stings, respectively) are reported. Clinical manifestation was characterized by diffuse and widespread edema, a burning sensation in the skin, headache, weakness, dizziness, generalized paresthesia, somnolence and hypotension. Acute renal failure developed and was attributed to hypotension, intravascular hemolysis, myoglobinuria due to rhabdomyolysis and probably to direct toxic effect of the massive quantity of injected venom. They were treated with antihistaminic, corticosteroids and fluid infusion. One of them had severe acute renal failure and dialysis was required. No clinical complication was observed during hospital stay and complete renal function recovery was observed in both patients. In conclusion, acute renal failure after bee stings is probably due to pigment nephropathy associated with hypovolemia. Early recognition of this syndrome is crucial to the successful management of these patients.

Acute tubulointerstitial nephritis after wasp stings

A 61-year-old Caucasian man presented with acute renal failure after multiple wasp stings. The patient required dialysis support temporarily. Work-up failed to show rhabdomyolysis or hemolysis and a kidney biopsy revealed acute allergic interstitial nephritis. The patient's renal function recovered completely after a short course of steroid therapy. Acute renal failure after wasp stings is typically caused by acute tubular necrosis in the setting of hemolysis or rhabdomyolysis. Compared with previously reported cases of acute renal failure associated with bee stings, our patient is unique in that his renal failure was caused by a hypersensitivity reaction apparently to the wasp venom.

Myoglobinuria

Myoglobinuria refers to an abnormal pathologic state in which an excessive amount of myoglobin is found in the urine, imparting a cola-like hue, usually in association with myonecrosis and a clinical picture of weakness, myalgias, and edema. Myoglobinuria is produced by multiple causes: any condition that accelerates the use or interferes with the availability of oxygen or energy substrates to muscle cells can result in myoglobinuria, as can events that produce direct muscle injury, either mechanical or chemical. Acute renal failure is the most serious complication, which can be prevented by prompt, aggressive treatment. In patients surviving acute attacks, recovery of muscle and renal function is usually complete.

Acute renal failure in experimental envenomation with Africanized bee venom

Human victims of multiple bee or wasp stings have been reported and develop severe clinical signs and symptoms. Acute renal failure (ARF), usually due to acute tubular necrosis (ATN) was a frequent complication. The pathogenetic mechanisms of ATN occurring in these accidents are still unclear. In the present study, female Wistar rats weighing 150-200 g were injected intravenously with Africanized bee venom at a dose of 0.4 microL/100 g body weight, and the kidney was observed under light and transmission electron microscopy and in immunohistochemical studies. The animals were divided into two groups: an Early group studied 3 to 8 hours after inoculation, and a Late group studied 24 to 30 hours after inoculation. The animals showed ATN mainly in the cortex and outer medulla with cast formation. After 24 hours, frequent mitotic figures were found in the tubular epithelium. Immunohistochemical studies revealed the presence of myoglobin and muscle actin in the tubular casts. Under electron microscopy, proximal tubule segments showed increasing intracytoplasmic vacuoles and attenuation of the brush border and of the basolateral infolding. This segment and the thick ascending limb of Henle's loop showed hydropic degeneration. Dead cells with apoptosis or necrosis due to cellular disintegration resulted in tubular basement membrane denudation. In the Late group, figures of intracytoplasmic myelin could be observed, some of them containing mitochondrial fragments. These changes are likely to be due to interactive effects of venom components, mainly mellitin and enzymes such as phospholipases, both acting on biological membranes. The ATN found was probably due to multiple causes, mainly a direct action of the venom on tubular cells, myoglobinuria, and perhaps ischemic mechanisms.

Myoglobinuria, malignant hyperthermia, neuroleptic malignant syndrome and serotonin syndrome

This article presents an overview of the causes and manifestations of myoglobinuria and provides criteria for its diagnosis and management. The article also reviews neuroleptic malignant syndrome, malignant hyperthermia, and serotonin syndrome, all of which could cause rhabdomyolysis and myoglobinuria.

Fatal multiple organ failure following massive hornet stings

We describe a fatal outcome in a three-year-old child following massive stings by the oriental hornet (Vespa orientalis). The primary clinical features were coma, respiratory failure, coagulopathy, renal failure and liver dysfunction. On postmortem the main organs involved were brain, lungs, kidney and liver.