Intracranial haemorrhages due to wasp sting – A case report

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Abstract

Introduction Hymenoptera stings are a common occurrence worldwide. Most of the deaths related to Hymenoptera stings are the result of anaphylaxis. However, till date there have been rare reports of neurovascular complications and very few autopsy reports. Due to its rarity and unestablished pathogenesis, we review the existing literature on possible mechanisms of stroke following a wasp or bee sting and the clinical implications of the same. In our literature search, a total of only 6 hemorrhagic strokes were found. This portrays the rarity of the manifestation. Case Details A 55-year-old male presented to the casualty, with sudden onset unilateral weakness of left upper and lower limb for 1 day. The weakness developed one day after an insect bite on his right middle finger. He had a local inflammatory reaction on his right middle finger in the form of a swelling, with no redness and tenderness. Motor examination revealed decreased power in his left upper and lower limb with a grading of one, with hyper-reflexia and a positive Babinski sign on the left side. Non-contrast enhanced CT showed a large intraparenchymal hemorrhage involving the right gangliothalamocapsular region extending into the intraventricular area with perilesional edema and midline shift to the left side, subarachnoid hemorrhage in bilateral fronto-parietal sulcal spaces and along the falx cerebri. Examination of the brain showed intracerebral hemorrhage over the right basal ganglia region. The cause of death after autopsy was opined as due to complications of intracerebral hemorrhage because of a wasp/bee/insect sting being a possibility. Clinical Implications The pathophysiology of stroke due to a Hymenopteran sting is unknown; however, we have reviewed the existing literature about the postulated mechanism. We can summarize the various postulated mechanisms of hemorrhagic stroke as: 1) Hypertensive state due to vasoactive amines released due to mast cell degranulation and chronotropic and ionotropic effect of catecholamines released due to endogenous stimulation by mellitin and histamine. 2) Anticoagulant activity of hyaluronidase and hemolysis due to phospholipase A2 predisposes to hemorrhage. 3) Direct toxigenic effect of the venom. 4) Ischemic infarct undergoing hemorrhagic transformation due to high reperfusion pressure or if the initial ischemia was severe. 5) Bee stings could pose a higher risk for hemorrhagic stroke due to mellitin which is exclusively present in bee venom. The incidence of presentation with neurological deficits/complications is rare, however one needs to keep such presentations in mind and refer the patient accordingly for appropriate management since there are no specific guidelines to manage such patients.

Original languageEnglish
Pages (from-to)169-172
Number of pages4
JournalJournal of Punjab Academy of Forensic Medicine and Toxicology
Volume23
Issue number1
DOIs
Publication statusPublished - 01-01-2023

All Science Journal Classification (ASJC) codes

  • Pathology and Forensic Medicine
  • Toxicology

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