Acute kidney injury following multiple bee stings

Sir,

Bee stings are a well-known form of envenomation in the tropics. The most common forms of toxicity are local and systemic allergic reactions. Acute renal failure (ARF) following bee stings is an uncommon complication.[1]

We present a 7-year-old male child who was stung by numerous (described by onlookers as approximately 50) honey bees while playing in a rural semi forested district in Uttarakhand, India. He was stung predominantly on the scalp, face, neck, upper limbs and trunk [Figure 1]. He was admitted to a local hospital where hydrocortisone and pheniramine maleate were administered for the pain, swelling and redness of affected areas. After 1-day patient was discharged and sent home. Posthoney bee stings, child had reddish urine (blood mixed) for 3–4 days.

Figure 1.

Child’s body showing few healed multiple bee sting lesions

Seven days later, the parents brought the child to our hospital as he was anuric for past 24 h. On the presentation to our hospital, the child was mildly irritable and restless. He had pallor, mild facial puffiness, pitting edema, and semi-healed erythematous sting marks over his entire body. Systemic examination revealed hepatomegaly, but chest was clinically clear with no crepitations or rhonchi.

The child had blood urea of 397 mg/dL and creatinine of 12.7 mg/dL. Urine showed 3+ proteinuria and micro hematuria. Urine for hemoglobin was positive and for myoglobin was negative. Kidney ultrasound revealed bulky kidneys with more echogenicity than normal and loss of corticomedullary differentiation at places.

The patient was transferred to the pediatric intensive care unit and treated with fluid restriction and broad-spectrum antibiotics. Emergency hemodialysis was performed for 3 consecutive days and 2 more on alternate days. After about 7 days, urine output started improving. After intensive supportive treatment and hemodialysis, the patient’s condition improved. His renal functions recovered gradually after about 1-month. On review after 4 weeks, his blood urea was 28.8 mg/dL and Serum creatinine was 0.7 mg/dL.

In India, existence of honey combs is general in rural as well as urban areas. But there is sparse data available in literature on bee sting toxicity. Although toxins of 500 stings are estimated to be capable of killing an adult, as few as 30 stings can cause fatal envenomation in children.[2] ARF can result from direct toxicity or following hemolysis, rhabdomyolysis or disseminated intravascular coagulation as extensively described by Deshpande et al.[3] Circulatory compromise due to anaphylaxis or dehydration can cause pre renal type of ARF. Acute tubular necrosis is the histological end result of these pathologies and acute tubular-interstitial nephritis also can occur in combination.[4]

It is important that the medical community is conscious of the need for rapid transfer of patients with multiple bee stings to higher medical centers due to the renal lesions that form part of the natural history of this type of venom injection. Also, because hemodialysis treatment must be started early in order to prevent complications and reduce mortality.[5] Early presentation to centers with optimal facilities may reduce morbidity and mortality in patients following multiple bee stings.