You may have recently seen news stories about Vespa mandarina “terrorizing” parts of China. What is interesting about this species is that due to their size, their venom has significant effects in addition to the typical hymenoptera anaphylaxis. Yes, most deaths are still from anaphylaxis, but the venom can cause acute renal and hepatic failures, as well as rhabdomyolysis.
This article describes a case report of a Japanese man who received multiple stings while in his yard. He was hypotensive and tachycardic, and as such received epinephrine. In addition to the epi you’re thinking of, he also received intrathecal epinephrine. He also received glycyrrhizin, an active component of licorice roots, commonly used in Japan for hepatitis and skin lesions. Apparently anaphylaxis is included in the “skin lesion” category. They also put gentamicin/steroid ointment on the stings. In spite of this treatment, the sting lesions became hemorrhagic, then necrotic. He also developed rhabdomyolysis and hepatitis.
In writing the case up, the authors did an Ichushi (Japan) literature search to find other cases of organ failure after Vespa stings. They ended up finding 14, and using their case came up with a grand total of 15. All of them had hepatitis and rhabdomyolysis, but surprisingly, 3 did not have anaphylaxis. Thirteen of the 15 had some degree of skin necrosis or hemorrhage, however. Six patients died, and when the data were analyzed, this correlated well with number of stings. Strangely, organ injury did not correlate as well, per the authors.
A Medline search was also performed, but they were unable to find any papers with photographic evidence. The few reports they found simply described the lesions, and some sounded similar to their experiences in Japan. Using written descriptions, they were able to find 15 more cases of wasp stings that had cutaneous manifestations and organ failure. There were also reports of bee sting cases in Zimbabwe, the United Kingdom, and Brazil with similar syndromes.
The authors agree with the Good Samaritan Regional Poison Center recommendation of admission for any pediatric, elderly, and patients with comorbidities if they have more than 50 stings. This seems like a good rule to follow for patients with a significant number of stings from any wasp, hornet, or bee. They also recommend being on the lookout for multiple organ failure if any of the stings become hemorrhagic or necrotic, as this implies either a stronger than usual venom, or a weaker than usual immune response. This seems like a reasonable clinical approach.
Yanagawa Y, Morita K, Sugiura T, Okada Y. Cutaneous hemorrhage or necrosis findings after Vespa mandarinia (wasp) stings may predict the occurrence of multiple organ injury: a case report and review of literature. Clin Toxicol (Phila). 2007 Oct-Nov;45(7):803-7. [PMID 17952752]
EBM Gone Wild