Late presentation of polyserositis following single honey bee sting: A case report

Abstract

Introduction and importance

The severity of a bee sting reaction can vary. There are two kinds of responses: local and systemic. The systemic manifestations are rare, especially polyserositis. Polyserositis describes the inflammation of serous membranes such as the pericardium, the pleura, or the peritoneum. We reported a case of polyserositis following a honeybee sting with late presentation.

Case presentation

This is a case report of a 30-year-old man who presented with progressive dyspnea, swelling of both lower limbs, and abdominal pain that began three days after the bite. CT showed pericardial, pleural, and abdominal fluid. Echocardiography showed tamponade. He underwent surgery to remove pericardial and pleural fluid. Following surgery, the patient underwent medical treatment. Ten days following treatment he developed a complete resolution of all symptoms and signs.

Clinical discussion

Bee stings can be life- threatening. Polyserositis occurring due to honey bee sting is a rare complication. The honey bee sting appeared to cause increased microvascular permeability. Pericardial, pleural effusion, abdominal ascites, and lower limb edema due to honey bee stings are infrequent complications. The physician should know enough about all the possible side effects of bee stings.

Conclusion

Physicians should be informed of the rare complications of bee stings. To prevent systemic complications medical treatment is recommended.

1. Introduction

Poisoning by toxins from insect stings poses an important health problem. Bee sting reactions were encountered in only 5 % of the patients [1]. Venom from bee stings triggers a cascade of immunological reactions in addition to its direct toxin effects on the serous membranes. Increased microvascular permeability is a primary pathological mechanism associated with such reactions. Polyserositis often presents with pericardial effusions, pleural effusions, and ascites. Bee sting should be treated as a medical emergency and prompt treatment should be instituted to prevent mortality and morbidity. We presented a young man who developed cardiac tamponade, bilateral massive pleural effusion (PE), and ascites within three days after a honey bee bite. Polyserositis after a honey bee sting is a very rare complication that was previously not reported. The work has been reported in line with the SCARE criteria and the revised 2023 SCARE guidelines [2].

2. Case presentation

A 30-year-old man presented with progressive dyspnea, swelling of both lower limbs, and abdominal pain that began three days after the bite. His past medical history included only a stab wound to the heart 2 years ago that underwent sternotomy and repair of the right ventricle. His blood pressure was 80/50 mmHg, and his pulse rate was 120 beats/min. He was 89 % O2 saturation on room air. Otherwise, he had no comorbidities disease, a physical examination showed a muffled heart sound and decreased breathing sounds over bilateral lower lung fields. The abdomen was distended and generalized tenderness was present. A shifting dullness was present. There is one site of stings along the dorsal side of his right foot. The sting lesion was red with central necrosis (Fig. 1). On laboratory tests, the white blood cell count was 12,000/ mm³. Other tests were normal. Computed tomography showed massive pericardial effusion, bilateral PE (Fig. 2), and ascitic fluid (Fig. 3). Echocardiography revealed a normal left ventricular ejection fraction and massive pericardial effusion with signs of cardiac tamponade. This presentation required an immediate and thorough medical evaluation to address the bee sting complications and subsequent symptoms. Due to the patient's clinical condition, no electrocardiogram (ECG) was taken and he was a candidate for emergency surgery. The tamponade was relieved by creating a pericardial window into the left pleural space. During the operation, 1200 mL of pericardial effusion, 1500 mL of right PE, and 800 mL of left PE were drained. Bilateral chest tubes were also inserted. After the operation, the symptoms began to subside and the patient felt comfortable. Pericardial, pleural, and abdominal fluid analysis revealed exudative effusion. Pericardial cytology was non-hemorrhagic, and the culture was negative. The smear study showed reactive mesothelial hyperplasia. Surgical pleural and pericardial biopsy showed acute polyserositis. Since the patient was diagnosed with hypersensitivity, he was treated with corticosteroids and diuretics. The selection of these drugs was based on strong clinical suspicion of polyserositis and appropriate clinical response. He completely recovered after 9 days of hospitalization and was discharged after ten days. At three weeks and six months after discharge, echocardiography and abdominal sonography were normal and the patient was doing well with no recurrence of symptoms.

Fig. 1.

Site of honey bee sting in dorsal of the right foot.

Fig. 2.

Chest and abdominal CT showed (a) massive bilateral pleural and pericardial effusion.

Fig. 3.

Massive ascitic fluid (arrow).

3. Discussion

A bee sting is a widespread injury. Bee venoms contain peptides, enzymes, and proteins [3] such as histamine-like active amines, melittin, phospholipase A2, mast cell degranulating peptide (peptide 401), hyaluronidase, and apamin [4]. Bee toxin can damage the vascular endothelial cells, increasing vascular permeability and polyserositis. The direct toxin effect on the serosal surface may play an additional role in the mechanism [5]. In this case, delayed reactions after the sting are more consistent with a Type III hypersensitivity reaction. Type III reaction may develop three to ten days after a sting [6]. We diagnosed bite-induced polyserositis by exclusion. There are no malignant cells in pericardial-pleural effusion. The cultures for bacteria were negative. The patient had no history of an autoimmune disease as the tests for autoantibodies were negative. Differential diagnoses consist of hypothyroidism and heart failure. Thyroid function was normal. Echocardiography showed normal ejection fraction, so hypothyroidism and heart failure- related effusion improbable. The presence of ascites, pericardial, and pleural fluid in this case is usually considered an ominous sign and more commonly seems to be associated with high morbidity. Lower limb edema was another sign indicative of plasma leakage. The case highlights the potential complications of bee stings. Interestingly, an immediate anaphylactic reaction did not occur. Instead, a delayed response leads to pleural effusion, pericardial effusion, and ascitic fluid within 72 h of the incident. Polyserositis is an inflammation with effusion of more than one serous membrane such as the pericardium, pleura, and peritoneum. The symptoms of bee bite may vary depending on the amount of the sting, the route, and host characteristics. Sometimes a single sting could be fatal [7]. Sting may result in a wide range of clinical symptoms ranging from localized pain to systemic anaphylaxis shock [8]. The clinical courses can be described as hyperacute, acute, subacute, or chronic. Hyperacute is characterized by a very rapid clinical course and can cause anaphylactic shock and death. Generalized edema, can occur in the subacute form. Treatment is essentially supportive. This report describes an uncommon but important aspect of bee sting and raises concerns that are not typically part of routine medical education. Education strategies are the best proactive approach to this potentially deadly emergency.

4. Conclusion

Detection of pleural effusion, pericardial effusion, ascites, or pedal edema following a bee sting may serve as crucial indicators for predicting hypersensitivity syndrome. We propose that endothelial damage and inflammation induced by honey bee stings could be underlying mechanisms contributing to the development of polyserositis. Further investigation is warranted to fully understand these associations and guide management strategies. The purpose of this report is to raise awareness of the dangers associated with bee stings and the importance of prompt medical and surgical treatment, as well as to contribute to the limited literature data on such cases.

Author contribution

BS wrote the manuscript, MJ reviewed it, and all authors approved the final version for publication.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethics approval is not required for case reports in Shahrekord University of Medical Sciences.

Guarantor

Behnam Shakerian.

Sources of funding

This research did not receive any specific grant form funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

All authors declare no conflict of interest.