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Case Note

Case Note: Dramatic Erythema and Edema

History

Dramatic erythema, edema of the entire side of the face with pronounced periocular involvement. Patient reports no lip, tongue, or laryngeal swelling, shortness of breath, malaise, dizziness, visual compromise, or headache.

Initial evaluation

  • The patient is placed in a supine position
  • Airway and circulation are assessed and are normal

 

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Enter your diagnosis

Diagnosis

  • Patient has been stung on the side of his face by a bee
  • The stinger is removed from the skin by tweezers; an ice-pack is applied to the sting site

Initial Treatment

  • The patient is given 50 mg oral diphenhydramine
  • After 10 minutes, the swelling begins to subside
  • The patient is escorted home and follows up with his primary doctor the next day

Follow-up evaluation strategy

  • The patient has moderate persistent hemifacial and periocular swelling; because the edema around his eye obstructs his vision, he is given a prescription for a 5-day course of prednisone 1 mg/kg/day
  • He is referred to an allergist for evaluation and consideration of venom immunotherapy
  • He is referred to an ophthalmologist for evaluation given the dramatic periocular involvement
  • He is given a prescription for supplies for an emergency kit: systemic antihistamines, systemic corticosteroids, and an epinephrine auto-injection pen to carry with him at all times

General discussion

The order hymenoptera includes bees, wasps, hornets, and ants. Hymenoptera stings cause toxic and allergic reactions.
Toxic reactions, also termed local reactions, result from the local tissue effects of venom containing histamine, hyaluronidase, mellitin, or phospholipase. Toxic reactions are often mild and last several hours. Localized pain, edema, fever, urticaria, serum sickness, and arthralgias may ensue. They can be severe or even fatal if a person is stung numerous times.

Allergic responses are Immunoglobulin E (IgE) dependent and present in previously sensitized individuals as a local exaggerated reaction or a generalized systemic (anaphylactic) reaction. Local exaggerated reactions are characterized by erythema, swelling, and itching which extend beyond the site of the sting. Anaphylaxis is characterized by rapidly developing symptoms which may compromise circulatory and respiratory symptoms. Anaphylaxis is a medical emergency requiring prompt diagnosis and immediate emergent management. Risk factors for anaphylaxis include a history of repeated stings and may be an occupational hazard for those frequently exposed to these insects; other associated risk factors include male gender, older age, elevated serum tryptase level, cutaneous or systemic mastocytosis, and medications such as angiotensin-converting enzyme inhibitors. Vespid (wasp) stings are more commonly associated with anaphylactic reactions.

Hymenoptera members have distinct stinging patterns. Most nest in the ground or in walls and sting only if provoked, with the exception of African bees. Honeybees typically leave a barbed ovipositor (stinger) in the skin, whereas bumble bees, wasps, and hornets can withdraw their stinger. Ant stings are painful and usually multiple; fire ant stings are notably painful. Tender urticarial lesions may result along with the development of a pruritic sterile pustule.

Any hymenoptera sting may cause eosinophilic cellulitis (Wells' syndrome) with flame figures seen on histopathology. Dramatic reactions, including anaphylaxis, may be a presenting manifestation of mastocytosis and is not likely mediated by IgE.

Further reading

Rueff F, et al. Management of occupational hymenoptera allergy. Curr Opin Allergy Clin Immunol 2011;11(2):69-74.

Rueff F, et al. Stinging hymenoptera and mastocytosis. Curr Opin Allerg Clin Immunol 2009;9:338-42.

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