Anaphylactic Shock Due to Bee Sting

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

A 45-year-old African American male (AAM) was taken to the local emergency department (ED) with anaphylactic shock. He was working on his house when he was attacked by bees. He was stung twice and subsequently experienced generalized body hives and decrease in systolic blood pressure (SBP) to the 80s per the emergency medical system (EMS) responders. The patient denied shortness of breath (SOB), nausea or vomiting (N/V), or tongue swelling on admission. There was no prior exposure or allergic reaction. Benadryl 25 mg IV and bolus IV fluids were given by EMS.

Past medical history (PMH)

Alcohol abuse, hypertension (HTN), smoking.

Medications

None.

Physical examination

Drowsy but following commands.
VS: BP 100/50, HR 101, RR 18, SpO2 93% on RA.
HEENT: bilateral swollen upper eyelids, no tongue swelling, posterior oral pharynx visualized.
Chest: CTA (B), no respiratory distress, no crackles or wheezing.
CVS: no murmurs, rubs or gallops, regular rate and rhythm.
Abdomen: Soft, NT, ND, + BS.
Extremities: no c/c/e.
Skin: generalized urticarial rash.

What is the most likely diagnosis?

Anaphylactic shock.

What would you do?

He was given:
Epinephrine 0.3 mg IM
Solumedrol 125mg IV
Benadryl 25 mg IV

What happened next?

The patient started to complain of sore throat. ENT consult was called who attempted to visualize the larynx with a fiberoptic scope but the patient was unable to cooperate due to exaggerated gag reflex.

His voice became hoarse, oxygen saturation decreased and he was re-examined by the ED physician who was not able to visualize the posterior pharynx. The anesthesiology team was called, etomidate and succinylcholine were used for paralysis, and ENT intubated the patient with a rigid laryngoscope on first attempt. Propofol infusion was started. ENT reported significant supraglottic swelling.

MICU team was called and the patient was admitted for mechanical ventilation and further treatment. Post-intubation chest X-ray showed appropriate ET tube placement. CBC and BMP were unremarkable. Urine toxic screen was positive for alcohol, and blood alcohol level was elevated.

The patient was on mechanical ventilation for 2 days and after successful extubation was transferred to a regular medical floor. His hospital course was complicated by delirium tremens due to alcohol withdrawal from which he recovered. He was discharged home with an EpiPen prescription and a follow-up appointment with an allergist.

Final diagnosis

Anaphylactic shock due to allergic reaction to bee sting.

What did we learn from this case?

Drugs used for management of anaphylaxis are remembered by the mnemonic EASI:

Epinephrine IM
Antihistamines PO, IM
Steroids PO, IM, IV
Inhaled b2-agonists, if wheezing; IV fluids, if hypotensive


Figure 1. Mind map diagram of anaphylaxis (click to enlarge the image).

Epinephrine (adrenaline) is the first-line the treatment of anaphylaxis. Adult intramuscular dose is 0.3 to 0.5 ml of 1:1,000 concentration. This should be given in the lateral aspect of the thigh by intramuscular injection. The dose can be repeated every 5 to 15 minutes, depending upon the response, for 3-4 doses. The same is true for children except the dose is 0.01 mg per kg (AAAAI Ask the Expert, 2012).

References

Stinging Insect Hypersensitivity: A Practice parameter Update. Joint Council of Allergy, Asthma, and Immunology.
Venom Allergy: A Short Review. V. Dimov, 08/2007.
Clinical review: ABC of allergies, Venom allergy. Pamela W Ewan. BMJ 1998;316:1365-1368.
Anaphylaxis guidelines by World Allergy Organization. JACI, 2011.

Clinical review: ABC of allergies, Anaphylaxis. Pamela W Ewan. BMJ 1998;316:1442-1445.
Anaphylaxis. eMedicine, 07/2005.
Anaphylaxis to stings and bites. Robert J Heddle. MJA 2006; 185 (5): 290.

Related Reading

CNN: Skateboarder's death underscores insect allergy risks. 5 percent of Americans are at risk for a severe, potentially life-threatening allergic reaction from insect stings http://bit.ly/3PEVtK

Beebearding is thought to date back to the 1700s http://goo.gl/j4nE'

Stinging Insect Matching Game. AAAAI.

Stinging Insect Guidelines - 2001 Update by AAAAI and ACAAI. Medscape, 2011.
Bee Aware Allergy - Insect allergy educational website by Hollister-Stier Laboratories.

Published: 08/24/2007
Updated: 06/15/2011