Delayed toxic reaction following massive bee envenomation

Massive bee envenomation can produce both immediate and delayed toxic react ion. Signs and symptoms of immediate toxic reaction are fatigue, nausea, vo miting, hemolysis, kidney failure, and disseminated intravascular coagulati on. The label "delayed toxic reaction" refers to a patient who is asymptoma tic after a massive bee envenomation, with normal initial laboratory result s, but later demonstrates laboratory evidence of hemolysis, coagulopathy, t hrombocytopenia, rhabdomyolysis, liver dysfunction, and disseminated intrav ascular coagulation. The subject of this case report, a 66-year-old man, wa s stung more than 125 times in an attack by Africanized bees. He was initia lly asymptomatic, except for pain, and his laboratory findings were normal. The first signs of his fatal multi-organ-system failure were not apparent until 18 hours after envenomation. This experience has led the Good Samarit an Regional Poison Center in Phoenix, AZ, to recommend a 24-hour hospitaliz ation for pediatric patients, older patients, and patients with underlying medical problems who are asymptomatic or who are experiencing only pain aft er an envenomation of 50 or more stings. Such patients have an increased ri sk of tissue injury, which may be delayed and which may be more effectively treated if identified early rather than on 12- to 24-hour follow-up. All o ther envenomated, asymptomatic patients or envenomated patients experiencin g only pain who become symptomatic or who belatedly exhibit laboratory valu es consistent with hemolysis, thrombocytopenia, rhabdomyolysis, liver dysfu nction, kidney failure, and disseminated intravascular coagulation within a 6-hour emergency department observation period should be admitted. Intrave nous fluids, blood products, dialysis, and other intensive measures should be initialed if necessary.