» Case Report

A 12-year-old boy presented to the Emergency Medical Services with a history of wasp sting while playing under trees near his house. He had remained asymptomatic for a period of eighteen hours after the sting apart from mild pain and tingling sensation at the site of the sting. Subsequently he developed intense pruritus and facial puffiness. He was taken to the local government hospital at 24 hours after the sting where he was treated with dexamethasone and chlorpheniramine maleate and referred to our hospital. On the way to our hospital he developed progressively worsening respiratory distress, irritability and disorientation. Time interval between sting and presentation at our emergency department was 26 hours. The parents did not give a family history of atopy or asthma.

At presentation he was irritable, tachypneic with a respiratory rate of 54/mt, with intercostal and subcostal retractions. His heart rate was 112/mt with weak peripheral pulses and unrecordable blood pressure. Pulse oximetry revealed an oxygen saturation of 70% while breathing 50% oxygen. Bilateral crepitations were present on auscultation. Heart sounds and JVP were normal and he had a normal liver span. Central nervous system examination was normal except for irritability.

He was immediately intubated and ventilated. He required PIP/PEEP of 27/15 and 100% FiO2 to maintain oxygen saturation of >85%. He was given three boluses of crystalloids (each 20ml/Kg) and started on adrenaline infusion, injection hydrocortisone, antihistamines (H1 and H2 blockers). His blood pressure (110/70 mm Hg) and pulse volume improved two hours after admission. At admission he had a urea of 105 mg/dl and creatinine of 1.5 mg/dL, with normal serum electrolytes. Arterial Blood Gas (ABG) revealed metabolic acidosis (pH: 7.18) and his peripheral smear showed crenated red blood cells, thrombocytopenia (Platelet count: 23,800) and neutrophilic shift to left. His liver enzymes were elevated (AST: 412, ALT: 358). Chest radiograph showed bilateral diffuse infiltrates with a normal cardiac shadow consistent with ARDS. He continued to require mechanical ventilation with high PEEP of 15 cm of water and FiO2 of 0.8 to 1 to maintain oxygenation during the next five days. Cultures of his body fluids (blood, urine) were sterile. The boy also had persistent oliguria with rising urea and creatinine values necessitating hemodialysis twice. He continued to be hemodynamically unstable requiring high dose of adrenaline and dobutamine infusions to maintain tissue perfusion. In spite of our best efforts, we could not salvage the patient and he died on the sixth day.

» Discussion

Our patient had unexpected fatal outcome from an unusual late onset reaction following a single wasp sting. Local and systemic reactions following multiple wasp stings are a known entity; but fatal complications following a single wasp sting are rarely reported. Fisher BA and Antonios TF reported occurrence of atrial flutter after a single wasp sting.