Acute Ischemic Stroke Due to Multiple Bee Stings_A Delayed Complication.

Sir,

Bee and wasp stings may rarely cause acute stroke. We present a case of a 41-year-old man who had a fatal right MCA territory stroke following an attack by over 50 bees.

This particular 41-year-old man with no previous comorbidities was attacked by over 50 bees while at the fields and lost consciousness. He was taken to a hospital where the stings were removed and symptomatic treatment with analgesics, corticosteroids and antihistamines was provided. With treatment, he regained consciousness and was walking independently. He was kept under observation.

Five hours later, patient developed sudden onset left hemiparesis and dysarthria with gaze preference to the right side. CT head showed massive right MCA territory infarction [Figure 1]. He was managed with dual antiplatelets. In spite of this, his sensorium deteriorated and he was started on low molecular weight heparin on the next day. He was also given intravenous mannitol. However, the patient continued to deteriorate and had to be endotracheally intubated. He was also given hyperventilation. However, the edema related to the infarct led to midline shift and the patient relatives refused surgery for decompression hemicraniectomy. The patient succumbed on the third day following the bee stings.

Figure 1

CT head showing hypodensity in the right middle cerebral artery territory suggesting infarction

Bee stings are commonly associated with local reactions like erythema, edema, redness and pain at the local site which are self-limiting. It may be associated with systemic effects such as anaphylaxis including hypotension and laryngeal edema. In a series of 322 cases[1] of wasp and bee stings reported by Witharana and colleagues, 79% had only local reaction and 4.6% developed anaphylaxis. None of them developed stroke or renal dysfunction. Only two patients had to be referred to tertiary care centre, of whom one had ocular stings and other had more than 1000 stings.

Bee stings are managed symptomatically. The first step is to remove the stings so that further exposure to the venom is stopped. Adrenaline, antihistamines and corticosteroids are usually administered to counteract local reaction as well as anaphylaxis. Patients who recover from anaphylaxis usually do not develop further symptoms. Rarely patients may develop organ dysfunction such as acute kidney injury, rhabdomyolysis, cardiac dysfunction including heart block, Takotsubo cardiomyopathy, myocardial infarction etc.[23]

Stroke associated with bee stings are limited to a handful of case reports only.[45678910111213] It may occur in the post-acute phase within 4 to 10 hours. Most of the reported cases are due to multiple bee stings.

The exact etiology of stroke following bee sting has not been elucidated. Proposed mechanisms are 1. Due to hypotension and reduced cerebral perfusion due to anaphylaxis, 2. Hypercoagulable state and platelet aggregation due to thromboxane A2 and phospholipase activation, 3. Vasoconstriction due to retrograde stimulation of the superior cervical ganglion and carotid spasm etc.

Stroke following bee sting is very rare. Clinical history and examination is of utmost importance in diagnosing the etiology of altered sensorium and stroke. In cases of multiple bee stings, patients often become unconscious and may not be able to provide history. Our patient was brought to the hospital in an unconscious state by the passersby. In such cases, careful general examination would reveal insect bite marks which would lead to the diagnosis. Awareness of this rare entity can lead to appropriate diagnosis and prevent unnecessary evaluation for the cause of stroke.

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