Hymenoptera heartaches -cardiac manifestation with hymenoptera stings, a retrospective study from a tertiary care hospital in South India
Introduction
Hymenoptera stings are commonly seen in rural parts of India and are usually associated with local symptoms such as pain, swelling and edema. Occasionally, systemic manifestations such as vasculitis, serum sickness, neuritis, and encephalitis have been reported [1]. One such complication which is reported in medical literature but can get missed and is underreported is acute myocardial infarction [2]. “Acute coronary syndrome associated with mast-cell and platelet activation in the setting of hypersensitivity and allergic or anaphylactic insults” is defined as Kounis Syndrome(KS) or allergic angina first described by Kounis and Zavras in 1991 [[3], [4], [5]]. KS is acknowledged as a “not rare but underdiagnosed” condition both due to little awareness of its existence among physicians as well as due to the shared pathogenesis and clinical manifestations with acute coronary events of ischemic etiology that shift focus away from a synchronous allergic response [6]. Other cardiac manifestations that may mirror KS are hypersensitivity myocarditis and even Takotsubo cardiomyopathy. By the means of this retrospective study, we hope to add to the existing pool of knowledge and do a comprehensive review of literature focussing on pathophysiology, clinical picture, and treatment of cardiac complications associated with Hymenoptera stings.
Section snippets
Methodology
After procuring IEC consent (854/2020) we conducted a record review of all cases ofhymenoptera stings that presented to our Emergency Medicine Department (ED) between October 2018–October 2020 using the emergency department registers, ICD code- T63.441A for medical record review and data from the VENOMS registry from December 2019 to October 2020. The VENOMS Registry is a CTRI registered single centric hospital based registry that includes all cases of envenomation presenting at the ED
Results
Six cases presented with hymenoptera stings that had concomitant cardiac manifestations. Of these, four were male and two female. All patients were elderly with a mean age of 71.7 years. All the cases reported multiple bee stings, involving predominantly the face and upper limbs. One patient was riding a two-wheeler and subsequently suffered a head injury. Most patients did not have any comorbidities, barring two who were hypertensive on treatment. The presenting complaints of the patients had
Hymenoptera species and distribution in the region
The identification of the culprit species in envenomation is of utmost importance in the emergency department. It will help direct initial diagnostics and the level of observation required. A concerted effort must be carried out in all cases.Hymenoptera is a large order of insects that include ants, wasps, sawflies, and bees. Of medical significance are the bees, wasps, hornets and some species of stinging ants. Of these, the bees and hornets are the most medically significant, responsible for
Conclusions/recommendations
Hymenoptera envenomation is globally significant, particularly in the tropics and temperate regions. Hymenoptera envenomation and Kounis syndrome must be considered for inclusion in academic medical curriculums even at the undergraduate level. At emergency departments initial evaluation and therapeutics for consideration but not limited to are mentioned in Table 3.
Credit author statement
Freston Marc Sirur - Conceptualization, Reviewing and Editing.
William Wilson – Methodology, Writing- Original draft preparation.
Vivek Gopinathan - Reviewing and Editing, Supervision.
Chethana AS – Data collection and analysis, images formatting.
Nymisha Lekha - Data collection and analysis, video formatting.
No funding/grants to declare.
Not presented at any organisations/seminar.
Declaration of Competing Interest
No conflicts to declare.
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2022, Tropical Medicine and Health