Article, Neurology

A different reason for cerebrovascular disease

Case Report

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American Journal of Emergency Medicine

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A different reason for cerebrovascular disease

Abstract

Bee stings are commonly encountered worldwide. Various manifestations after a bee sting have been described. Local reactions are common. Unusually, manifestations such as vomiting, diarrhea, dyspnea, generalized edema, acute renal failure, hypotension, and collapse may occur. Rarely, vasculitis, serum sickness, neuritis, and encephalitis have been described, which generally develop days to weeks after a sting. We report a case of a 35-year-old man who developed neurologic deficit 6 hours after a bee sting, which was confirmed to be left parietooccipital infarction on magnetic resonance imaging scan. We report this case due to its rarity.

Bee sting is one of the commonly encountered insect bites in the world. Allergic reactions are most commonly seen after a bee sting. Immunological response varies according to the individual’s immune structure [1,2]. Classical local reactions are usually common after a bee sting. Sudden burning, pain, itching, redness, and local swelling are seen [2,3]. Systemic toxic effects and anaphylaxis appear due to the neurotoxic, hemorrhagic, and hemolytic toxic effects of bee venom [2,4]. Accordingly, vasculitis, glomerulonephritis, nephrosis, serum disease, neurologic symptoms (convulsions, coma, and encephalitis), edema, vomiting, diarrhea, headache, hypotension, coagulation disorders, peripheral neuropathy, and renal failure may occur [5]. Here, we present a case who developed neurologic deficit 6 hours after the bee sting, and no other etiology was found.

A 35-year-old man patient was brought to our emergency department (ED) due to a change in consciousness after a bee sting. From the anamnesis of the patient, it was learned that a change in consciousness, dyspnea, and respiratory distress was developed after many bee stings. From his medical history, it was found that he had been subjected to many bee stings, but no allergic reactions have been developed before. After 0.5-mg adrenaline IM, 45.5-mg pheniramine, and 80-mg methylprednisolone IV were given to the patient at the scene by the medical team, he was brought to our ED. The performance status of the patient at the ED was mean, he was conscious, his blood pressure was 90/60 mm Hg, the respiratory rate was 30 per minute, and his pulse rate was 120 beats per minute. There was a sinus tachycardia in his electrocardiogram. He also had periorbital edema on his eyelids, generalized rhonci in all zones of both hemithoraces, and generalized hyperemic, erythematous-urti- carial lesions all around the body.

Adrenaline 0.3 mg IM, salbutamol nebul, 100-mg methylprednis- olone, and 50-mg ranitidine were ordered IV, and prompt 0.9% NaCl solution infusion was started. The patient was observed in a monitoring unit. In his sixth follow-up hour, a loss of function in the right upper and lower extremities was discovered. The cranial

computed tomography scan of the patient was normal (Fig. 1). However, diffusion magnetic resonance imaging of the patient showed a left MCA infarction (Fig. 2). In ECHO, carotid artery Doppler USG, and neck magnetic resonance angiography, no pathologic finding was found. The patient was consulted by neurology and then hospitalized for treatment and follow-up. Regarding etiology, laboratory evaluation included antineutrophil cytoplasmic antibody, anti-dsDNA, ANA, antithrombin 3, protein C and S, anticardiolipin, anti-SCL 70, anti-SSA, anti-SSB, activated protein C, antifosfolip S, M, and borrellia bur. Immunoglobulin (Ig) G and M and coagulation tests were all normal. The patient was discharged with neurologic sequela with the recommendation of physical training.

Bee sting cases are generally associated with mild and transient local symptoms. Sometimes life-threatening allergic reactions can occur[6]. Among these, the most important one is anaphylaxis, which can cause mortality. The incidence of anaphylaxis due to bee sting ranges between 0.4% and 5%. Mortality associated with Severe allergic reactions appears usually before the age of 20 years and was twice common in male population [7]. Classical local allergic reactions occur after bee sting, and the diagnosis depends on the history. In our case, the history and physical examination findings are compatible with local allergic reaction. A large number of bites can cause urticaria and systemic toxicity including cardiovascular and neurologic

Fig. 1.

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Fig. 2.

problems [8]. Systemic toxic reactions due to venom compounds are observed usually after 50 to 100 bee bites. Although adults can tolerate more than 1000 bee bites, sensitive individuals may develop mortal Anaphylactic reaction after one [9]. Our case is exposed to many bee bitings and developed systemic anaphylaxis reactions during the first hour of the incident. Although it varies in general population, systemic sensitivity increases after each bite, and developing reactions are more severe [10].

In this case, the patient has been exposed to bee stings many times, but systemic sensitivity did not develop until the last event. Systemic toxic reactions may develop related to the dose and structure of bee venom. These reactions may begin in the first hours and may last for several days, so they require a long-term follow-up. Our case was exposed to many bee stings, and central neurologic findings occurred at sixth hour after the incident due to the possible neurotoxic effects of the venom [9]. Neurologic findings after Multiple bee stings as in this case were rarely reported in the literature [11-14]. The etiological investigation in neurology ward where the patient was followed up and treated did not show any other agent, and this supports that the neurologic outcome is caused by the bee sting.

Reactions by bee sting are frequently mediated by IgE, but these reactions can also occur by IgG antibody and IgG venom complex triggered complement activation. Symptoms usually occur within the first few hours, but they can be observed even after hours or even days rarely [15]. The symptoms usually decline in the first few hours, but after 2 to 4 hours, relapse may occur. Therefore, patients should be observed for a period of at least 6 hours. In our case, reactions were observed after the first hour and decreased by the treatment of health teams, but at the sixth hour of the follow-up, neurologic symptoms were developed.

After a bee sting as well as local reactions, systemic toxic and anaphylactic reactions due to the person’s immune response can be

observed. For the likelihood of relapse development, patients must be warned and kept under observation in EDs at least 6 hours.

Ozlem Bilir Gokhan Ersunan Asim Kalkan Medical Faculty

Department of Emergency Medicine Recep Tayyip Erdogan University

Rize, Turkey E-mail address: [email protected]

Tuna Ozmen Medical Faculty Department of Neurology

Recep Tayyip Erdogan University

Rize, Turkey

Yahya Yigit

Medical Faculty Department of Emergency Medicine Recep Tayyip Erdogan University

Rize, Turkey

http://dx.doi.org/10.1016/j.ajem.2012.12.040

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