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Received for publication: 2.5.09; Accepted in revised form: 16.10.09
Nephrol Dial Transplant (2010) 25: 1146–1150
doi: 10.1093/ndt/gfp583
Advance Access publication 23 November 2009
Swarming hornet attacks: shock and acute kidney injury—a large case
series from Vietnam
Bich Huyen Nguyen Xuan1, Hoa Le Mai1, Tan Xuan Nguyen Thi1, Minh Trinh Huynh thi1,
Huu Nhan Nguyen2 and Rahmin A. Rabenou3,4
1
Nephrology Section, Cho Ray Hospital, Ho Chi Minh City, Vietnam, 2Emergency Department, Pediatric Hospital Number One, Ho
Chi Minh City, Vietnam, 3Southeast Asia Program, NYU School of Medicine, New York, NY, USA and 4Nephrology Division, NYU
School of Medicine, New York, NY, USA
Correspondence and offprint requests to: Rahmin Rabenou; E-mail: [email protected], [email protected]
Abstract
Background. Social hornets attack victims in swarms in
Asia, Africa and the Middle East. The venom consists of
multiple proteins with myotoxin, haemotoxin, vasodilatory
and anticoagulant effects.
Methods. We reviewed the records of 65 patients at Cho
Ray Hospital (Ho Chi Minh City, Vietnam) attacked by
swarms of the lesser banded hornet, Vespa affinis. Patients
were divided into four groups. Groups A and B presented
within 3days of attack and C and D after 3days with ≤50 or
>50 stings, respectively.
Results. Varying degrees of acute kidney injury (AKI)
were seen in 38 (58.5%) patients in all groups. Twenty nine
required renal replacement therapy. AKI was likely to be
myoglobin and toxin induced with a clinical course consistent with acute tubular injury. The prognosis for renal recovery is excellent in those who survive. Seven patients
(one from Group A and six from Group B) developed
© The Author 2009. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: [email protected]
Hornet Attacks: Shock and Acute Kidney Injury–A Large Case Series From Vietnam
non-anaphylactic shock which led to four deaths. The predominant finding in Groups C and D who sought delayed
tertiary care is renal failure.
Conclusions. This cases which illustrate the varied effects
of hornet venom and the need to be vigilant for shock within
the first 2days and persistent AKI beyond 3days of attack.
Keywords: acute kidney injury; hornet; rhabdomyolysis
Introduction
There is an extensive literature detailing the anaphylactic
effects of stinging insects that largely belong to the order
Hymenoptera, which includes bees, ants and wasps. Anaphylaxis can occur after one or a few stings by solitary
bees or wasps. Severe non-anaphylactic reactions due to
massive envenomation occur after multiple stings by social
wasps which attack interlopers in swarms in defense of
their hive. Wasp venom includes multiple components:
acetylcholine, histamine, serotonin, phospholipase A, hyaluronidase, catecholamines, histamine-releasing peptides
(mastoparans), chemotactic peptides and neurotoxic kinins. Kinins are a painful repellant against large vertebrate
intruders, whereas in smaller prey they lead to paralysis
[1]. Phospholipases contribute to haemolysis and rhabdomyolysis. Since serum venom levels in most envenomations do not reach clinical importance except in cases of
anaphylaxis, haemo- and rhabdomyolysis are usually seen
only in massive attacks [2].
The family Vespida includes solitary and social wasps,
yellow jackets and hornets. The systemic and toxic effects
of vespid venom can include acute kidney injury (AKI),
haemolysis, rhabdomyolysis, liver impairment and coagulation abnormalities [2–7]. This study examines the largest
case series of patients following attack by swarming hornets
who presented to Cho Ray Hospital (CRH) in Vietnam over
a 10-year period. Patients were stung by a single species,
Vespa affinis (lesser banded hornet; Figure 1), which is endemic to Southeast Asia. These insects typically build large
nests on high tree branches or under overhangs. They are
disturbed during human activity such as roof repairs or children throwing stones at their nests, which can be very large.
During flooding, waters can reach to the top of the trees.
People passing by in boats can inadvertently disturb the
nests. Unlike bees with barbed stingers, the Vespidae
(wasps, hornets and yellow jackets) species have no barbs
and can sting repeatedly without damaging or losing the
stinging apparatus (Figures 2 and 3).
Results
Incidence of AKI and haemodialysis treatment
A total of 38 patients (58.5%) exhibited varying degrees
of AKI def ined as a creatinine level of 1.5 mg/dL
(132.6 μmol/L) or higher. Twenty nine of these patients
required haemodialysis (Table 1). The average creatinine
phosphokinase (CPK) level was higher in patients requiring dialysis: 18 942.1 vs 3555.4 mg/dL (median 44 321 vs
1147
1475.5 mg/dL) in non-dialysis-requiring patients. Nine patients requiring dialysis had CPK values <2000 IU implying other mechanisms for AKI. There was an average of
3.9 haemodialysis sessions per patient. Survivors had complete recovery of renal function.
Amongst patients presenting within 3 days, Groups A
and B (Figure 1), there is an increased risk for combined
AKI and need for dialysis in Group B with ≥50 stings:
10.3% vs 78.5%. Since patients with <50 stings are less
likely to seek medical attention, 10.3% is likely an overestimate. All patients in Groups B and C developed AKI.
These groups largely represent patients transferred for tertiary care or those who tolerated the initial effects of stings
but later became increasingly ill from AKI. Although a
large percentage of patients in Groups C and D, 60%
and 70.6%, respectively, required dialysis, Group C only
consists of five patients compared to 17 in Group D. Even
in late presenters, sting burden likely carries a larger risk
for AKI and need for dialysis.
Hematologic complications
Coagulation disorders are commonly seen and appear to
be related to venom dose. In Group A, five patients
(19%) have partial thromboplastin times (PTT) ≥40s (normal 23–36 s). The mean partial thrombin (PT) is 15.5 s
(normal <12.0 s). In Group B, eight (57%) have PTT values of ≥40 s. The mean PT and PTT are 18.2 and 66.3 s,
respectively. In Groups C and D, the only elevated mean
value is a mean PTT of 47.8 s in Group D. Although anaemia commonly developed during hospitalization, blood
smears and haptoglobin values are not available to differentiate toxin-induced and microangiopathic haemolysis
from anaemia due to AKI and acute illness. In Groups A
and B, patients present with mean haematocrit levels of
40% and 38.5%, respectively. In patients with elevated
PTTs, one had overt gastrointestinal bleeding and three
had difficult-to-control puncture site bleeding.
Presence of shock and mortality
On presentation to CRH or local clinics, patients were typically treated with steroids and antihistamines. At CRH,
seven patients presented or developed persistent hypotension despite attempted resuscitation with IV fluids, more
steroids, epinephrine and vasopressor support. They
lacked allergic symptoms such as wheezing and urticaria.
The mortality in this group was very high; four died.
Their ages ranged from 22 to 75 years old with a median
age of 54. All are from the early presentation group: six
from Group B and one patient with 36 stings from Group
A. They endured an average of 80 stings compared to an
average of 63.8 stings for all of Group B. The mean PT
and PTT for the group was 21.2 and 97.5 s, respectively,
more than any of the other groups. Rhabdomyolysis was
prominent in all but one patient with a mean CPK level
of 19 771.3. Thrombocytopaenia was also common at presentation with a mean platelet count of 97.5×103 cells/mL
(Table 1).
A 24-year-old pregnant patient admitted to a provincial
hospital initially responded to resuscitation and was trans-
1148
B.H. Nguyen Xuan et al.
Fig. 1. All patients were stung by Vespa affinis (lesser banded hornet), a
20–25 mm hornet which is endemic to large areas of Asia including
southern Vietnam in areas typically inhabited by humans.
Fig. 2. The wasp stinger and venom sac has no barbs (unlike honey bees)
and can be used for repeated stinging without anchoring and detaching in
its victim.
ferred to CRH 3 days later for recurrence of hypotension
and persistent dialysis requiring oliguria. Laboratory evaluation revealed a CPK-MB of 2540 IU and a total CPK/
CPK-MB ratio of 44%. She survived with complete recovery of renal function; however, she lost the fetus. The other
patients with hypotension did not have significantly elevated MB isoenzymes. One patient, who expired, developed
progressive jaundice with hypotension, which may have
been due to obstructing biliary stones.
A striking finding in this group is the delayed development of hypotension. Hypotension typically occurred
within 2–3days of attack. This was not seen in any patients
from Groups C and D and was most prevalent in Group B,
suggestive of a dose-dependent effect.
event, is the predominant finding in Groups C and D. All
had AKI and 68.2% required renal replacement therapy.
Venom hepatotoxicity
Bilirubin levels were measured in 20 patients. Sixteen patients had total bilirubin levels >1.5 mg/dL (25.7 μmol/L)
with a range of 2.2–28.0 mg/dL (37.6–478.8 μmol/L). Interpretation of transaminase levels in these patients is diff icult due to concurrent rhabdomyolysis. One case
involved a 22-year-old female who sustained over 100
stings and rapidly became jaundiced and died on Day 32
with a total bilirubin of 28mg/dL (478.8 μmol/L).
Correlation of the number of stings and time of
presentation with severity of outcome
Discussion
Patients with >50 stings had a higher mortality (19.3% vs
3.2%) and, as expected, increased co-morbidities including
AKI (90.3% vs 25.8%) and shock (22.5% vs 6.4%). Six of
eight overall deaths occurred in Group B with the highest
mortality at 42.9%. AKI in late presenters, >3 days after the
Attack by swarming social hornets or bees is a worldwide
problem. This is the only large case series to describe this
phenomenon. We report on 65 patients presenting to CRH
in Ho Chi Minh City, Vietnam after multiple stings by V. affinis (the lesser banded hornet). Hymenoptera venom to-
Table 1. Characteristics of patients stung by swarms of hornets
Group
A
B
C
D
Hypotension group
Age
Sting number
Renal failure n (%)
Creatinine mean (median), mg/dL
Haemodialyis n (%)
Rhabdomyolysis n (%)
Refractory hypotension n (%)
Deaths
PT (s)
PTT (s)
Haematocrit
Platelets×103 cells/mL
CPK (IU)
AST (IU/L)
ALT (IU/L)
43.9
22.1
4 (15.4%)
1.6 (0.9)
3 (12%)
14 (53.8%)
1 (3.4%)
1 (3.8%)
15.5
40.0
39.7%
190.7
2257.7
348.9
131.1
48.6
76.5
12 (85.7%)
6.2 (6.8)
11 (78.5%)
8 (57.1%)
6 (43%)
5 (36%)
18.2
66.3
38.5%
127.4
31 949
1424.6
667
48.6
21.4
5 (100%)
9.9 (10)
3 (60%)
2 (40%)
0
0
14.4
34.3
29.2%
200
3867
309.1
273.3
55.5
63.9
17 (100%)
10.7 (8.5)
11 (65%)
7 (41.1%)
0
1 (5.8%)
15.1
47.8
33.7%
175.7
8834.9
661.2
345.0
54.2
86
4 (57%)
3.4 (3.1)
4 (57%)
5 (71%)
4 (57%)
21.2
97.5
39.8%
103
19 771.33
1132.8
465.6
Patients were divided into two groups: presenting within 3days (Groups A and B) and after 3days (Groups C and D). They were subdivided based on
the number of stings: <50 stings (Groups A and C) and ≥50 stings (Groups B and D). The Hypotension group consists of one patient from Group A and
six from Group B. Percentages are based on individual groups.
Percent of Affected Subjects By
Group
Hornet Attacks: Shock and Acute Kidney Injury–A Large Case Series From Vietnam
120
1149
Complications of Massive Hornet Attack
100
80
60
40
20
0
Renal Failure
Group A
Venom Induced
Shock
Group B
Group C
Group Mortality
Rate
Group D
Fig. 3. Two wasp stings characterized by induration and central necrosis.
xicity is attributed to haemolytic, myotoxic, neurotoxic, vasodilatory, nephrotoxic and hepatotoxic enzymes. Signs and
symptoms in our patients included shock, rhabdomyolysis,
AKI, bleeding and liver dysfunction. The patients were divided into four groups based on their presentation to a tertiary care facility. Groups A and C were stung with <50
stings and arrived in CRH within or after 3 days of attack,
respectively. Groups B and D sustained ≥50 stings and presented within or after 3 days of the attack, respectively.
Although all patients presenting after 3days had AKI,
there were more deaths in the early presenters who are
the only groups at risk for venom-induced shock. This risk
is higher with more stings. Hypotension is not due to immediate type anaphylaxis. Other than hypotension, patients
lacked other signs for this. A direct vasodilatory effect of
hornet venom, particularly at high doses, may be responsible. Three patients with shock survived. One was a young
pregnant woman with an elevated CPK-MB; she lost her
fetus. The MB isoenzyme may have had a cardiac or uterine source. Although we expect immediate anaphylaxis to
occur, in rural Vietnam these victims may not reach medical attention in time.
There are multiple case reports of paediatric deaths following attacks by Vespa species; we do not have data to
confirm that young children are at higher risk for death,
but this possibility has been raised in Israeli subjects where
a different hornet, Vespa orientalis, is the predator. In patients attacked by the Oriental hornet, haemolysis appears
more prominent [8–10]. At Pediatric Hospital Number One
in Ho Chi Minh City from 1999 to 2000, 45 children (2:1
male/female ratio) were admitted: 41 stung by hornets and
Fig. 5. Renal failure, shock and mortality correlate with the number of
stings and days to presentation with shock only occuring within the
first 3 days.
three by honey bees. The mean number of stings and CPK
levels were 70.2 and 31 428IU, respectively. Twelve developed AKI with nine requiring dialysis. Two died due to
infections related to peritoneal dialysis.
AKI developed in varying degrees in more than half our
patients. Most patients required renal replacement therapy
for treatment of oliguria refractory to intravenous fluids.
AKI due to hornet stings has been previously reported secondary to pigment-induced (either heme- or myoglobin)
acute tubular necrosis and also to biopsy-proven acute interstitial nephritis [11]. We also suspect a direct toxic effect
from the venom on the renal tubules, particularly in those
lacking elevated CPK levels and acute tubular necrosis due
to hypotension-induced ischaemia. A hypothesis of direct
toxic effects of venom components on renal tubules has
been proposed.
Intermittent haemodialysis was performed an average of
3.9 times before the recovery of kidney function occurred.
The anticoagulant effect of the venom can complicate
treatment. The prognosis for the recovery of kidney function is excellent among survivors, which is consistent with
the course of acute tubular injury from other causes.
As expected, Group A with the lowest sting burden had
the least number of complications. While the most striking
feature in Group B is the shock syndrome and death, in
Groups C and D, it is AKI requiring renal replacement therapy (Figure 5). We suspect that Group B underestimates the
risks of shock. There may be patients with hypotension who
die before reaching CRH either from anaphylaxis or from
Total Number of Patients
n=65
Patients Presenting Within 3
Days
n=43
Group A
Patients with <50
stings
n=29
Group B
Patients with >50
stings
n=14
Patients Presenting After
3 Days
n=22
Group C
Patients with <50
stings
n=5
Group D
Patients with >50
stings
n=17
Fig. 4. 65 patients were divided into those presenting within 3 days and after 3 days and further subdivided by the number of stings, <50 stings and ≥50
stings.
1150
the direct vasodilatory effects of venom. We also suspect
that we overestimate AKI in Group A. Large numbers of
people with <50 stings likely never seek medical attention.
Physicians in Vietnam have been alerted to the risks of
rhabdomyolysis and AKI after hornet attacks. In district
hospitals, they now initiate treatment with intravenous
fluids on presentation and are vigilant for the development
of AKI. Personal observations at CRH indicate that fewer
patients are now presenting with AKI. Our colleagues at
Oxford have developed an antivenom antibody and enzyme-linked immunoassay to measure serum venom levels.
We hope to use this to correlate venom levels with number
of stings and risks for specific clinical complications.
Methods
The case series consists of 65 patients admitted to CRH (Ho Chi Minh City,
Vietnam) following multiple wasp stings typically in the spring and summer months. Upon admission, the patient’s history was obtained including
time, location and description of the insects, and initial symptoms. Each
patient was examined for the number, location and characteristics of the
stings. The patients were followed closely with particular attention to their
urine output, kidney function and other pertinent laboratory tests. Haemodialysis was instituted at the discretion of the treating physician.
The insects involved in the attacks were brought by the patients' families who collected the insects at night by lighting fires which attract and
stun the insects. Specimens were sent to the Hope Entomological Collections, University Museum of Oxford, for identification.
The case histories of 65 patients treated at CRH in the period from 1989
to 2000 were evaluated retrospectively. For the purposes of data analysis,
the patients were subdivided based on the time of presentation (within 3
days and after 3days from being stung) to CRH and on the number of stings
sustained (<50 stings and ≥50 or more stings), as represented in Figure 4.
Acknowledgements. The authors wish to acknowledge Dr. David Warrell
(Professor of Tropical Medicine and Infectious Diseases, Oxford University), Dr. David Theakston (Emeritus Professor, Liverpool School of
Tropical Medicine), Mr. Chris O'Toole (Oxford Bee Company) and Dr.
V. Agrawal et al.
Keith Arnold (Head of International Clinical Research for Southeast Asia,
Roche Research Foundation (ret.)) for their early encouragement and
guidance. An abstract of this work was posted at the World Congress
of Nephrology (ISN) in Singapore in 2005.
Conflict of interest statement. None declared.
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Received for publication: 12.4.09; Accepted in revised form: 12.10.09
Nephrol Dial Transplant (2010) 25: 1150–1157
doi: 10.1093/ndt/gfp619
Advance Access publication 27 November 2009
In-hospital outcomes with thrombolytic therapy in patients with renal
dysfunction presenting with acute ischaemic stroke
Varun Agrawal1, Baroon Rai2, Jonathan Fellows3 and Peter A. McCullough4
1
Renal Division, Baystate Medical Center, Springfield MA, 2Section of Nephrology and Hypertension, University of Oklahoma
Health Sciences Center, Oklahoma City, OK, 3Division of Neurology, William Beaumont Hospital, Royal Oak MI and 4Divisions of
Cardiology, Nutrition and Preventive Medicine, William Beaumont Hospital, Royal Oak MI
Correspondence and offprint requests to: Varun Agrawal; E-mail: [email protected]
Dr. Agrawal and Dr. Rai were in the Department of Internal Medicine, William Beaumont Hospital, Royal Oak MI when this study
was conducted.
Abstract
Background. Thrombolytic therapy is an effective treatment
modality for acute ischaemic stroke within 3 hours of symptom onset. Its safety and efficacy have not been studied in
patients with chronic kidney disease (CKD), who are known
to have abnormalities in coagulation and platelet function.
Methods. We studied all patients who consecutively received intravenous thrombolytic therapy for acute stroke
© The Author 2009. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
For Permissions, please e-mail: [email protected]