Severe Clinical Impact of Multiple Wasp Stings: A Case Report of Acute Kidney Injury

ABSTRACT


Introduction
Insect bites are often caused by Hymenopterans, which belong to three major families: Apidae (bees), Vespidae (wasps), and Formicidae (ants). 1 Indonesia is home to a wide variety of wasps.Wasps exhibit a high level of aggression when protecting their nests. 2Contrary to bees, wasps can retract their stingers from their victim's skin and then fly away.Wasps can sting multiple times without limitation. 1e incidence of Hymenopteran stings is distributed in several regions of Indonesia.

Case Illustration
A 51-year-old female patient experienced edema anasarca during the previous 48 hours.The woman was transported to the local hospital two hours after getting stung.She had conservative therapy and wound cleansing before being transferred to a general hospital.At the second hospital, the patient first received conservative treatment.However, after careful observation, it was determined that the patient needed hemodialysis.As a result, the patient was then referred to Rasyida Kidney Hospital.During the examination, we discovered a total of 103 sting wounds on the patient's body.Specifically, there were 36 wounds on the left leg, 11 on the right leg, 22 on the right hand, 9 on the left hand, 12 on the chest, 5 on the face, and 8 on the back.These wounds varied in size, ranging from 0.5x0.5 cm to 1x1 cm.Several wounds developed into ulcers, while minor wounds started to heal.The patient exhibited symptoms including dyspnea, facial edema, emesis, cephalalgia, reduced urinary output, and edema anasarca.The patient had no prior medical conditions or preexisting renal problems.All vital indicators were within the normal range except for an elevated respiratory rate.The patient was administered a large dosage of methylprednisolone intravenously and followed by oral dosages during her outpatient treatment.On the twelfth day of treatment, the patient experienced acute upper gastrointestinal bleeding, even though she had been receiving proton pump inhibitor therapy since the first day she was admitted.During the following three days, the patient was treated with PPI therapy until the symptoms of upper gastrointestinal bleeding resolved.In addition, the patient presented with oral candidiasis infection, which was characterized by dysphagia and the presence of oral thrush.The edema anasarca was gone entirely on the final day of the treatment.The patient was discharged from the hospital after confirming the absence of digestive problems and an improvement in appetite.

Discussion
The venom of Hymenoptera contains several bioactive chemicals, including toxins, enzymes, activators, growth factors, and inhibitors. 4,5  typical local reaction is characterized by pain and swelling that persists for more than 24-48 hours and resolves within 5-10 days. 6Kinin is the primary cause of pain, where vasoactive amines are responsible for edema, and tissue damage is mediated by enzymes such as phospholipase and hyaluronidase.A localized reaction occurred for this patient, characterized by swelling in the 103 locations of the sting wound.
An excessive quantity of venom can lead to systemic toxin reactions due to multiple stings, ranging from fifty to hundreds or even thousands of stings.The extensive venom stimulates an inflammatory reaction that involves the release of pro-inflammatory cytokines IL-1β, TNF-α, and IL-6, resulting in generalized inflammation and damaging tissues.As a result, chemical mediators such as histamine, leukotrienes, prostaglandins, and thrombocyte activators are released, interfere with the coagulation system, and cause hemoconcentration.Within 24 hours, it may develop into hemolysis, hemoglobinuria, rhabdomyolysis, elevated liver transaminase enzymes, interstitial nephritis, renal insufficiency, and electrolyte imbalances may develop due to rhabdomyolysis. 1 Administering high-dose steroid therapy as the first line of treatment is advantageous in preventing the progression of interstitial nephritis, which can develop in patients with acute kidney injury following a wasp sting. 7,8  management of acute kidney injury resulting from insect stings is similar to the management of acute kidney injury in individuals with pre-existing kidney problems. 9,10 modialysis is effective in eliminating smallsized substances from the bloodstream.In case of poisoning caused by toxic substances, dialysis may be performed to eliminate toxic substances from the body rapidly.The requirement for dialysis is not determined by the severity of renal impairment in this type of condition.The Acute Dialysis Quality Initiative (ADQI) created the RIFLE method to diagnose and categorize different types of acute kidney problems. 11In this patient, a reduction in eGFR to 15 (mL/min/1.73m²)was observed on the second day as well as the production of urine is less than 0.1 mL per kilogram of body weight per hour.
The appropriate timing to start Renal Replacement Therapy (RRT) in patients with acute kidney injury cannot be ascertained.The initiation of RRT is primarily determined by the clinical manifestation of excessive fluid accumulation and the biochemical indication of an imbalance in solute levels (such as hyperkalemia and severe acidosis). 11Several studies have shown that initiating dialysis early when there are signs of renal function decline can effectively improve kidney function and patient prognosis and potentially save numerous lives. 7,9ost patients who experience acute kidney injury due to wasp stings require temporary RRT until their clinical condition improves and their kidney excretory function is restored to its normal state. 12Metabolic acidosis in patients with acute kidney injury would normally be resolved by administering bicarbonate and rarely requires urgent dialysis unless there is simultaneous volume overload or uremia.When deciding to stop RRT in patients with acute kidney injury, it is important to consider the goal of improving kidney function.The decision whether or not to stop RRT is determined by urine production. 11he patient decided on RRT, specifically hemodialysis, soon after discovering a significant decrease in kidney function accompanied by relevant clinical problems.During the patient's stay, hemodialysis was performed in 5 sessions.The interval between hemodialysis sessions was not uniform but instead adjusted according to the patient's clinical status.The patient experienced a reduction in edema anasarca, leading to a decrease of 6 kg in body weight during treatment.While in the hospital, the patient was administered sodium bicarbonate intravenously and then orally to treat metabolic acidosis.
Diuretics are frequently used in the management of patients with AKI to control fluid imbalance.Furthermore, oliguric acute kidney injury is associated with a more adverse outcome compared to non-oliguric acute kidney injury.Consequently, physicians frequently use diuretics to convert oliguric acute kidney injury to non-oliguric acute kidney injury.Diuretics are used to control fluid imbalance and facilitate the administration of nutrition and drugs.diuretics have renoprotective effects that can prevent the development of acute kidney injury and accelerate the process of recovery. 11The patient's condition, marked by the presence of edema anasarca, pulmonary edema, and anuria since admission, suggests the need for intravenous furosemide treatment to promote diuresis.The patient had anuria, with urine production less than 0.1 mL per kilogram per hour for 7 days.Throughout the first 10 days of treatment, the patient's urine output over 24 hours consistently remained below 400 mL.Following four hemodialysis treatments, the patient's kidney function started to improve on the 11th day of therapy.This recovery continued until the patient was discharged with a consistent increase in urine volume and eGFR.After the medical care, the patient's urine increased to a total volume of 3100 mL.Diuretics were administered continuously throughout until the patient was discharged from the hospital.The edema anasarca consistently reduced, with an average weight loss of 0.3 kg per day during the first 7 days and 0.5 kg per day during the subsequent 8 days.

Conclusion
This case illustrates the essential effect of promptly receiving medical treatment following an enormous wasp sting on the patient's prognosis.Initiating dialysis promptly is crucial for rapidly eliminating toxins and thus preserving renal function.Furthermore, the administration of high-dose steroids as an initial treatment has been scientifically proven to be effective.The management of cases involving numerous wasp stings can be effectively managed due to the improvements in healthcare services.
Between 2017 and July 2022, Indonesia has recorded 125 incidences of wasp stings, resulting in 12 deaths.The management of the Handling Program for Diseases Caused by Bites/Stings of Poisonous Animals and Poisonous Plants is still inadequate.The Ministry of Health and National Standard Operating Procedures provide instructions for the management of cases involving bites or stings from venomous animals and plants.The limited supply of antivenom is a contributing factor to the ongoing challenge of managing these patients.3