Acute kidney injury following rhabdomyolysis due to multiple wasp stings

Tahmina Jesmin; Rina Biswas; Abdullah-Al Mamun; Mst Shanjida Sharmim; Syed Saimul Huque; Afroza Begum; Ranjit Ranjan Roy

doi:10.4103/pnjb.pnjb_17_22

CASE REPORT

Year : 2022 | Volume : 7 | Issue : 2 | Page : 73-77

Acute kidney injury following rhabdomyolysis due to multiple wasp stings

Tahmina Jesmin, Rina Biswas, Abdullah-Al Mamun, Mst Shanjida Sharmim, Syed Saimul Huque, Afroza Begum, Ranjit Ranjan Roy
Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Date of Submission	23-Jun-2022
Date of Acceptance	20-Jul-2022
Date of Web Publication	22-Nov-2022

Correspondence Address:
Dr. Tahmina Jesmin
Department of Pediatric Nephrology, Bangabandhu Sheikh Mujib Medical University, Dhaka 1000
Bangladesh

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pnjb.pnjb_17_22

Abstract

Wasp stings are a common form of envenomation in tropical countries. Multiple wasp stings may cause fatal complications such as anaphylactic reactions, intravascular hemolysis, rhabdomyolysis, acute kidney injury (AKI), or even death also. Here we report a 9-year-old boy who was admitted to a tertiary care hospital in Bangladesh with complaints of multiple wasp stings all over the body 15 days back. He had oliguria and generalized edema for 7 days. The urine test was negative for red blood cells and his renal function was gradually deteriorating. His serum creatinine phosphokinase was gradually rising. Intermittent hemodialysis through a central venous catheter was started immediately. Renal biopsy revealed myoglobin cast nephropathy. On the basis of history, clinical manifestations, and laboratory investigation, he was diagnosed as AKI following rhabdomyolysis due to multiple wasp stings. Clinical and biochemical picture started to improve including urine output was normalized on seventh day of post-admission. Timely initiation of dialysis and supporting therapy can improve renal survival in case of AKI due to wasp stings.

Keywords: Acute kidney injury, hemodialysis, rhabdomyolysis and wasp stings

How to cite this article:
Jesmin T, Biswas R, Mamun AA, Sharmim MS, Huque SS, Begum A, Roy RR. Acute kidney injury following rhabdomyolysis due to multiple wasp stings. Paediatr Nephrol J Bangladesh 2022;7:73-7

How to cite this URL:
Jesmin T, Biswas R, Mamun AA, Sharmim MS, Huque SS, Begum A, Roy RR. Acute kidney injury following rhabdomyolysis due to multiple wasp stings. Paediatr Nephrol J Bangladesh [serial online] 2022 [cited 2023 Jun 3];7:73-7. Available from: http://www.pnjb-online.org/text.asp?2022/7/2/73/361616

Introduction

Wasp is a member of the vespid subgroup in the order hymenoptera that typically stings following provocation. It usually occurs in the late summer and early fall.^[1] Wasp venom is a complex substance consisting of proteins that can affect various tissues.^[2] Wasp and bee stings are associated with a wide variety of reactions ranging from mild local reactions (such as edema, erythema, and urticaria) to fatal systemic complications (such as anaphylactic shock, rhabdomyolysis, acute kidney injury (AKI), myocardial infarction, acute hepatic failure, and encephalitis).^{[3],[4],[5],[6]} AKI due to wasp is an uncommon but serious complication. It is usually caused by toxic-ischemic type mechanism as hypovolemia, intravascular hemolysis, rhabdomyolysis, and shock. Multiple wasp or bee sting venom is responsible for direct toxic effects such as AKI, hemolysis, and rhabdomyolysis.^[7],[8] Here we have reported a case who was presented with oliguria followed by AKI due to multiple wasp stings and was managed successfully.

Case Report

A 9-year-old boy, first issue of his non-consanguineous parents, was admitted to a tertiary care hospital with complaints of multiple wasp stings all over the body mostly on face, head, back, upper limbs, and lower limbs while playing under a tree 15 days back followed by vomiting for 14 days. He developed severe pain at the sites of the sting and was treated in the emergency department of a secondary care hospital with some injectable and oral drugs. But his urine output gradually decreased in amount and frequency and generalized swelling developed, which was starting from the periorbital region for 7 days before admission. There was no bleeding from the affected site, jaundice, history of taking any offending drugs, or familial nephropathy. He was conscious but fretful, puffy, mildly pale, and vitally stable and bipedal pitting edema, scrotal swelling, and ascites were present. The findings of the other systemic examinations were normal.

On skin survey, about 60 wasp stings of different sizes (0.5 cm × 0.5 cm to 1 cm × 1 cm) were present over the whole body, mostly on the back and buttock and focally on the head. Some lesions were ulcerated, whereas some were blackish and healed [Figure 1]. Bedside urine color was red and bedside urine albumin (BSUA) was (1+).

Figure 1: Multiple lesions of different sizes present on the skin of the back

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Investigations report revealed he was moderately anemic (hemoglobin 8.4 g/dL) with neutrophilic leukocytosis (total count of white blood cell [WBC] 16500 /cu mL of blood, neutrophil 76%), c-reactive protein negative, raised blood urea (serum urea 369.4 mg/dL), and serum creatinine (creatinine 16.5 mg/dL) with normal serum albumin (albumin 31g/dL) and estimated glomerular filtration rate (eGFR) was 3.25 mL/min/1.73 m².

Serum electrolyte showed hyperkalemia (K–6.8 mmol/L) with acidosis (total blood carbon dioxide [TCO2] 11 mmol/L). His circulating eosinophil count was raised (825 /cu mL), urine routine microscopy examination showed mild proteinuria, pyuria with a granular cast but red blood cell (RBC) was absent though dipstick showed RBC positive. Urinary sodium was 64 mmol/L and urinary eosinophil was 2.5% (normal <1%). Coagulation profile and liver function tests were normal except slightly raised alanine transaminase level (71 U/L). Serum lactate dehydrogenase (LDH) was 722 U/L and creatinine phosphokinase (CPK) level was raised from 222 U/L to 923 U/L. Echocardiography and chest X-ray-normal––ultrasonogram of the renal system––showed both kidneys were echogenic with moderately maintained cortico-medullary differentiation. On the basis of history, clinical manifestations, and laboratory investigations, the patient was diagnosed as AKI due to multiple wasp stings.

After resuscitation and supportive measures, he was managed with intravenous methylprednisolone for six consecutive days (1 g/day) and intermittent hemodialysis (HD) through a central venous catheter was started immediately. Our initial diagnosis was AKI due to acute interstitial nephritis and so methylprednisolone was prescribed to prevent inflammation. In the first session of HD, his prescription was as follows: duration 58 min, ultrafiltration 400 mL, blood flow 110 mL/min, dialyzer size 1.1 m², and in bicarbonate bath with 2 mL heparin loading. A total of 22 HD sessions were given. Following HD, his clinical and biochemical picture started to improve. Urine output gradually increased. Serum creatinine [Figure 2] and blood urea [Figure 3] level gradually decreased [Figure 3]. eGFR was gradually improved to normal levels on the 15th day of post-admission. In the meantime, his renal biopsy was done (8th day after admission) and the report showed myoglobin cast nephropathy [Figure 4]. At the 29th day of post-admission, our patient was discharged with a scheduled follow-up. During discharge his vitals were normal and output was adequate and biochemical parameter was normal.

Figure 2: Creatinine trend throughout the disease period

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Figure 3: Urea trend throughout the disease period

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Figure 4: Renal histopathology: myoglobin cast nephropathy has shown (marked with arrow)

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Discussion

Commonly reported insect bites are members of the hymenoptera family, such as bees, wasps, flies, and ants. Multiple wasp stings may cause fatal complications, such as anaphylactic reactions, intravascular hemolysis, rhabdomyolysis, AKI, increased levels of liver enzymes, clotting abnormalities, or even death.^[1],[9]

Clinical symptoms following wasp stings depend on the number of stings, venom strength, and patient’s immunity. Morbidity or mortality usually occurs after 20–200 wasp stings.^[10],[11] But Watana stated about 500 stings may be fatal to an adult due to direct toxicity; however, as few as 30–50 stings led to fatalities in children and even anaphylactic shock can occur in a previously sensitized person, following even a single sting.^[8] Our patient had more than 60 sting marks all over his body.

In temperate climates, stings may occur during warmer seasons, but their numbers peak in August.^[12]

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). Phospholipase A2 initiates inflammation, hyaluronidase causes the spread of venom, melitin has hemolytic, vasoactive, contractile, and cellular antimembrane properties, histamine increases vascular permeability and apamine is a neurotoxin.^[13],[14]

The local reactions following wasp bite include pain and swelling, whereas systemic allergic reactions may be mild, moderate (angioedema, asthma, and abdominal pain), or severe (laryngeal edema, hypotension, loss of consciousness).^[15],[16]

Anaphylaxis is a frightful complication that occurs within the first few hours after the stings. Following this liver injury, coagulation derangements, rhabdomyolysis, or hemolysis can occur which peak in one to three days. This ultimately followed by kidney injury that peaks in four to nine days in susceptible patients.^[17] In the present case, anaphylactic reaction (hypersensitivity) of wasp venom was suspected with the evidence of the significant increase of circulating eosinophil count (825 /cu mL) though we did not do immunoglobulin E(Ig E) level.

Melittin and phospholipase cause rhabdomyolysis, following a toxic action on striated muscle which also acts on RBC to induce hemolysis.^[15] It has been postulated that myoglobin released from muscles induces AKI by toxic effects on tubular epithelial cells through intralobular cast formation or pigment nephropathy. In addition, myoglobin is a potent inhibitor of nitric oxide bioactivity and may trigger intrarenal vasoconstriction and ischemia in patients with borderline renal hypoperfusion. Atmaram had shown in his review that 7 out of the 12 cases of wasp stings had rhabdomyolysis.^[18] Deshpande had also shown five cases of rhabdomyolysis out of nine cases of wasp stings.^[19] In present case, we have also found evidence of rhabdomyolysis and hemolysis. The cause of AKI in our patient is myoglobin cast nephropathy based on renal biopsy [Figure 4]. However, the urinary myoglobin level was not examined. Clinically patient had anemia with low Hb and peripheral blood film showed anisopoikilocytosis with pencil cells. Urine color was red although RBC was not present in urine routine examination. A gradual increase in CPK and LDH levels also indicates ongoing hemolysis. In renal biopsy, we have also found evidence of acute interstitial nephritis without apparent abnormality in glomeruli, and numbers of eosinophils count were greater in urine and blood.

AKI is responsible for approximately 25% of mortality in the early onset of disease due to multiple wasp stings. Therefore, it is worth monitoring renal function following the stings.^[9]

To determine the renal lesion, renal biopsy is recommended especially when renal function deteriorates or does not improve.^[20]

Prognosis depends on the time interval between getting stung and hospital admission. Immediate management is essential and starts with the removal of the stingers and prompt identification of toxin-related complications.^{[21],[22],[23]}

Wasp sting has no specific treatment, and wasp venom has no antidote. The primary principles of wasp sting management are (1) correcting hypovolemia to prevent renal ischemia; (2) enhancing the clearance of heme proteins, toxins, or toxic wastes out of the systemic or renal circulation; and (3) reducing the risk of direct venom toxicity, toxic waste, electrolyte imbalance, and heme protein in the kidney and other organs.^[24] The primary therapeutic goal is to prevent volume depletion, tubular obstruction, and aciduria, which can cause AKI. In present case, initially we had maintained hydration (calculated iv fluid) for volume replacement and treated with iv NaHCO₃ for urine alkalization and acidotic breathing. Our patient had received fluid, injectable antihistamines, and steroid with the suspicions of anaphylaxis and interstitial nephritis. As steroids reduce interstitial fibrosis in acute interstitial nephritis and leading to early renal recovery and preventing irreversible kidney damage.^[20] Our patient was also treated with prednisolone.

Renal complication does not occur as rapidly as anaphylactic reaction; Reduced diuresis may occur within 1–9 days after the stings.^{[11],[21],[25]} In the present case, after 7 days of the incident, oliguria developed. Once overt renal failure developed, the only treatment was dialysis. Approximately 11% of the AKI following wasp stings require one or more renal replacement therapy (RRT) modalities.^[18],[25] In our case, intermittent HD was given and the response was excellent after getting 22 HD sessions.

AKI following wasp stings is reversible in most cases. Different studies showed that the necessity of replacement therapy to return kidney function to normal status in AKI following wasp stings is as long as 3–6 weeks.^[26],[27] Our patient‘s renal function had come to normal on the 15th day of post-admission and was discharged on the 29th day of post-admission.

The most important factor that extremely affects the prognosis of AKI due to wasp stings is the duration between the sting attack and the patient’s arrival at the hospital as well as the management started.^[10],[28] A multicenter, retrospective study in China concluded that patients who were late arriving to the hospital (>4 h), had multiple wasp stings (≥20 stings), and developed AKI could have a good outcome when HD was performed immediately.^[10] Kidney function should be continuously monitored for up to 4–8 months because the condition may still progress into chronic kidney disease.^[29]

Although our patients had delayed hospital admission to the tertiary hospital, fluid treatment had been administered for the first few days, so slowed down the progressive development of AKI. But immediate dialysis had been started and selection of an accurate modality successfully eliminated wasp toxins and promoted the achievement of complete recovery of kidney function.

Conclusion

Children with multiple wasp stings should be hospitalized immediately and need to start treatment promptly followed by daily monitoring of progressive symptoms and follow up frequently throughout life. Immediate replacement therapy is the choice of treatment and can promote kidney function recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

References

1.	Ryakitimbo A, Kennedy M, Shao E, Itana ME, Mbwasi R, Kinabo G, et al. Acute kidney injury in a Tanzanian boy following multiple bee stings in resource-limited setting: A case report. Oxf Med Case Reports 2018;2018:omy070.
2.	Singh LR, Singh YT, Singh S, Singh NSK, Sharma LR Acute renal failure in a child following multiple wasp stings. Indian J Nephrol 2005;15:95-7.
3.	Lin CJ, Wu CJ, Chen HH, Lin HC Multiorgan failure following mass wasp stings. South Med J 2011;104:378-9.
4.	Chatterjee M, Deb S, Pandit N Encephalitis following wasp sting. Indian J Pediatr 2010;77:1193-4.
5.	Xuan BH, Mai HL, Thi TX, Thi MT, Nguyen HN, Rabenou RA Swarming hornet attacks: Shock and acute kidney injury: A large case series from Vietnam. Nephrol Dial Transplant 2010;25:1146-50.
6.	Zhang L, Tang Y, Liu F, Shi YY, Cao Y, Xu H, et al. Multiple organ dysfunction syndrome due to massive wasp stings: An autopsy case report. Chin Med J (Engl) 2012;125:2070-2.
7.	Thiruventhiran T, Goh BL, Leong CL, Cheah PL, Looi LM, Tan SY Acute renal failure following multiple wasp stings. Nephrol Dial Transplant 1999;14:214-7.
8.	Watana D, Anuwuthinawin D, Khoprasert S, Limpokiyagul PVS Multiple wasp stings in children a review. Chula Med J 1989;33:659-64.
9.	Ambarsari CG, Sindih RM, Saraswati M, Trihono PP Delayed admission and management of pediatric acute kidney injury and multiple organ dysfunction syndrome in children with multiple wasp stings: A case series. Case Rep Nephrol Dial 2019;9: 137-48.
10.	Xie C, Xu S, Ding F, Xie M, Lv J, Yao J, et al. Clinical features of severe wasp sting patients with dominantly toxic reaction: Analysis of 1091 cases. PLoS One 2013;8:e83164.
11.	Chowdhury FR, Bari MS, Shafi AM, Mumith A, Hossain ME, Chowdhury S, et al. Acute kidney injury following rhabdomyolysis due to multiple wasp stings (Vespa affinis). Asia Pac J Med Toxicol 2014;408:2013-5.
12.	Diaz JH Hymenopterid bites, stings, allergic reactions, and the impact of hurricanes on hymenopterid-inflicted injuries. J La State Med Soc 2007;159:149-57.
13.	Schumacher MJ, Egen NB Significance of africanized bees for public health. A review. Arch Intern Med 1995;155:2038-43.
14.	Habermann E Bee and wasp venoms. Science 1972;177:314-22.
15.	Mejía Vélez G [Acute renal failure due to multiple stings by Africanized bees. Report on 43 cases]. Nefrologia 2010;30:531-8.
16.	Golden DB Insect sting anaphylaxis. Immunol Allergy Clin North Am 2007;27:261-72, vii.
17.	Broides A, Maimon MS, Landau D, Press J, Lifshitz M Multiple hymenoptera stings in children: Clinical and laboratory manifestations. Eur J Pediatr 2010;169:1227-31.
18.	Atmaram VP, Mathew A, Kurian G, Unni VN Acute renal failure following multiple wasp stings. Indian J Nephrol 2005;15:30-2.
19.	Deshpande PR, Farooq AK, Bairy M, Prabhu RA Acute renal failure and/or rhabdomyolysis due to multiple bee stings: A retrospective study. N Am J Med Sci 2013;5:235-9.
20.	Chao YW, Yang AH, Ng YY, Yang WC Acute interstitial nephritis and pigmented tubulopathy in a patient after wasp stings. Am J Kidney Dis 2004;43:e15-9.
21.	Ghosh JB, Roy M, Bala AK Delayed onset interstitial nephritis following multiple wasp stings. Indian J Nephrol 2009; 19:71-3.
22.	Warrell DA Venomous bites, stings, and poisoning. Infect Dis Clin North Am 2012;26:207-23.
23.	Paudel B, Paudel K A study of wasp bites in a tertiary hospital of western Nepal. Nepal Med Coll J 2009;11:52-6.
24.	Dongol Y, Shrestha RK, Aryal G, Lakkappa BD Hymenoptera stings and the acute kidney injury. EMJ Nephl 2013;10:68-75.
25.	Vikrant S, Parashar A Acute kidney injury due to multiple hymenoptera stings-a clinicopathological study. Clin Kidney J 2017;10:532-8.
26.	Dhakal AK, Basnet NB, Shrestha D Acute kidney injury due to multiple wasp stings in an eight-year-old child. J Kathmandu Med Coll 2013;2:145-7.
27.	Vetter RS, Visscher PK, Camazine S Mass envenomations by honey bees and wasps. West J Med 1999;170:223-7.
28.	Zhang L, Yang Y, Tang Y, Zhao Y, Cao Y, Su B, et al. Recovery from AKI following multiple wasp stings: A case series. Clin J Am Soc Nephrol 2013;8:1850-6.
29.	Dhanapriya J, Dineshkumar T, Sakthirajan R, Shankar P, Gopalakrishnan N, Balasubramaniyan T Wasp sting-induced acute kidney injury. Clin Kidney J 2016;9:201-4.