eMedicine Specialties > Emergency Medicine > Environmental

Hymenoptera Stings: Differential Diagnoses & Workup

Author: Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Coauthor(s): Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center
Contributor Information and Disclosures

Updated: Apr 9, 2009

Differential Diagnoses

Acute Coronary Syndrome
Corneal Laceration
Arthritis, Rheumatoid
Snake Envenomations, Cobra
Bites, Human
Snake Envenomations, Coral
Catscratch Disease
Snake Envenomations, Mohave Rattle
Cavernous Sinus Thrombosis
Snake Envenomations, Sea
Cellulitis
Toxicity, Antihistamine

Other Problems to Be Considered

Dermatosis
Foreign bodies
Intravenous drug abuse
Local infection

Workup

Laboratory Studies

  • Diagnosis usually is confirmed by patient's history. In systemic reactions, laboratory studies may help evaluate organ damage caused by the reaction.
    • Complete blood count (CBC)
    • Chemistry

Procedures

  • Stinger removal
    • The stinger most commonly appears as a dark barb in the skin with attached stinging apparatus.
    • People who have been stung should remove the bee stinger as quickly as possible. Removal method is not as important as rapidity because the stinging apparatus actively injects venom into the wound for 1 minute after the sting, even if the bee has been killed or knocked away from the site. Visscher and colleagues demonstrated no advantage to scraping away the stinger compared with pinching.2
    • Forceps may be needed to remove the stinger after the venom sac has been torn away.

More on Hymenoptera Stings

Overview: Hymenoptera Stings
Differential Diagnoses & Workup: Hymenoptera Stings
Treatment & Medication: Hymenoptera Stings
Follow-up: Hymenoptera Stings
Multimedia: Hymenoptera Stings
References
Further Reading
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References

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  2. Visscher PK, Vetter RS, Camazine S. Removing bee stings. Lancet. Aug 3 1996;348(9023):301-2. [Medline].

  3. Rekik S, Andrieu S, Aboukhoudir F, Barnay P, Quaino G, Pansieri M, et al. ST Elevation Myocardial Infarction with No Structural Lesions after a Wasp Sting. J Emerg Med. Mar 26 2009;[Medline].

  4. Vachvanichsanong P, Dissaneewate P. Acute renal failure following wasp sting in children. Eur J Pediatr. Jan 16 2009;[Medline].

  5. Agarwal V, Singh R, Chauhan S. Parkinsonism following a honeybee sting. Indian J Med Sci. Jan 2006;60(1):24-5. [Medline].

  6. Agarwal V, Singh R, Chauhan S, D'Cruz S, Thakur R. Parkinsonism following a honeybee sting. Indian J Med Sci. Jan 2006;60(1):24-5. [Medline].

  7. Agostinucci W, Cardoni AA, Rosenberg P. Effect of papain of bee venom toxicity. Toxicon. 1981;19(6):851-5. [Medline].

  8. Ariue BK. Multiple Africanized bee stings in a child. Pediatrics. Jul 1994;94(1):115-7. [Medline].

  9. Awai LE, Mekori YA. Insect sting anaphylaxis and beta-adrenergic blockade: a relative contraindication. Ann Allergy. Jul 1984;53(1):48-9. [Medline].

  10. Betten DP, Richardson WH, Tong TC. Massive honey bee envenomation-induced rhabdomyolysis in an adolescent. Pediatrics. Jan 2006;117(1):231-5. [Medline].

  11. Charpin D, Birnbaum J, Vervloet D. Epidemiology of hymenoptera allergy. Clin Exp Allergy. Nov 1994;24(11):1010-5. [Medline].

  12. Chen CJ, Richardson CD. Bee sting-induced ocular changes. Ann Ophthalmol. Oct 1986;18(10):285-6. [Medline].

  13. Cohen SG, Bianchine PJ. Hymenoptera, hypersensitivity, and history: a prologue to current day concepts and practices in the diagnosis, treatment, and prevention of insect sting allergy. Ann Allergy Asthma Immunol. Mar 1995;74(3):198-217; quiz 217-21. [Medline].

  14. Davis K. Africanized honey bees. 1997.

  15. De Soto H, Turk P. Cimetidine in anaphylactic shock refractory to standard therapy. Anesth Analg. Aug 1989;69(2):264-5. [Medline].

  16. Fitzgerald KT, Flood AA. Hymenoptera stings. Clin Tech Small Anim Pract. Nov 2006;21(4):194-204. [Medline].

  17. Freye HB, Ehrlich B. Acute myocardial infarction following hymenoptera envenomation. Allergy Proc. Mar-Apr 1989;10(2):119-26. [Medline].

  18. Goldstein NP, Rucker CW, Klass DW. Encephalopathy and papilledema after bee sting. JAMA. 1964;188:1083-1084. [Medline].

  19. Hay SM, Hay FA, Austwick DH. Case report. Bee sting brachial block. Arch Emerg Med. Dec 1992;9(4):369-72. [Medline].

  20. Hiran S, Pande TK, Pani S, Gupta R, Vishwanathan KA. Rhabdomyolysis due to multiple honey bee stings. Postgrad Med J. Dec 1994;70(830):937. [Medline].

  21. Hur W, Ahn SK, Lee SH, Kang WH. Cutaneous reaction induced by retained bee stinger. J Dermatol. Dec 1991;18(12):736-9. [Medline].

  22. Janik JE, Wania-Galicia L, Kalauokalani D. Bee stings--a remedy for postherpetic neuralgia? A case report. Reg Anesth Pain Med. Nov-Dec 2007;32(6):533-5. [Medline].

  23. Karamloo F, Schmid-Grendelmeier P, Kussebi F. Prevention of allergy by a recombinant multi-allergen vaccine with reduced IgE binding and preserved T cell epitopes. Eur J Immunol. Nov 2005;35(11):3268-76. [Medline].

  24. McDougle L, Klein GL, Hoehler FK. Management of hymenoptera sting anaphylaxis: a preventive medicine survey. J Emerg Med. Jan-Feb 1995;13(1):9-13. [Medline].

  25. Patrick A, Roberts L, Poon-King P, Jeelal V. Acute renal failure due to multiple stings by Africanised bees. Report of the first case in Trinidad. West Indian Med J. Mar 1987;36(1):43-4. [Medline].

  26. Pucci S, Antonicelli L, Bilo MB. Shortness of interval between two stings as risk factor for developing Hymenoptera venom allergy. Allergy. Dec 1994;49(10):894-6. [Medline].

  27. Reisman RE. Unusual reactions to insect stings. Curr Opin Allergy Clin Immunol. Aug 2005;5(4):355-8. [Medline].

  28. Roll A, Schmid-Grendelmeier P. Ultrarush immunotherapy in a patient with occupational allergy to bumblebee venom (Bombus terrestris). J Investig Allergol Clin Immunol. 2005;15(4):305-7. [Medline].

  29. Schmidt JO. Let's not forget crawling Hymenoptera. Clin Exp Allergy. Jun 1994;24(6):511-4. [Medline].

  30. Schumacher MJ, Tveten MS, Egen NB. Rate and quantity of delivery of venom from honeybee stings. J Allergy Clin Immunol. May 1994;93(5):831-5. [Medline].

  31. Shimizu T, Hori T, Tokuyama K, et al. Clinical and immunologic surveys of Hymenoptera hypersensitivity in Japanese forestry workers. Ann Allergy Asthma Immunol. 1995;74(6):495-500. [Medline].

  32. Stablein JJ, Lockey RF. Adverse reactions to ant stings. Clin Rev Allergy. May 1987;5(2):161-75. [Medline].

  33. Stafford CT, Hutto LS, Rhoades RB, et al. Imported fire ant as a health hazard. South Med J. Dec 1989;82(12):1515-9. [Medline].

  34. Valentine MD. Allergy to stinging insects. Ann Allergy. Jun 1993;70(6):427-32. [Medline].

  35. Valkanas MA, Bowman S, Dailey MW. Electrocardiographic myocardial infarction without structural lesion in the setting of acute hymenoptera envenomation. Am J Emerg Med. Nov 2007;25(9):1082.e5-8. [Medline].

  36. Vetter RS, Visscher PK, Camazine S. Mass envenomations by honey bees and wasps. West J Med. Apr 1999;170(4):223-7. [Medline].

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Further Reading

Clinical guidelines

Stinging insect hypersensitivity: a practice parameter update. Moffitt JE, Golden DB, Reisman RE, Lee R, Nicklas R, Freeman T, deShazo R, Tracy J, Bernstein IL, Blessing-Moore J, Khan DA, Lang DM, Portnoy JM, Schuller DE, Spector SL, Tilles SA. Stinging insect hypersensitivity: a practice parameter update. J Allergy Clin Immunol 2004 Oct;114(4):869-86.

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Keywords

bee stings, yellow jacket sting, hornet sting, ant stings, wasp stings, vespid stings, bee envenomations, Hymenoptera envenomations, ant envenomations, wasp envenomations, vespid envenomations, Apis species, wasps, ants, severe anaphylactoid reactions, angioedema, respiratoryarrest, fatal allergic reactions, urticaria, confluent red rash

syncope, anxiety, confusion, wheezing, tachypnea, hypotension, laryngoedema, lingular edema, uvular edema, delirium, shock, honeybee stings, Africanized honeybee, , isoamylacetate, pheromone, apiotherapy, fire ants, , fire ant venom, Harvester ants, species

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Contributor Information and Disclosures

Author

Hemant H Vankawala, MD, Attending Physician, 24 Hour Emergency Room, Houston and Dallas; Attending Physician, Baylor University Medical Center; Medical Director, Big Bend National Park; Medical Director, Terlingua Fire and EMS; Medical Director, MedCare Ambulance Company
Hemant H Vankawala, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Randy Park, MD, Chair, Associate Professor, Department of Emergency Medicine, Denton Regional Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Dan Danzl, MD, Chair, Department of Emergency Medicine, Professor, University of Louisville Hospital
Dan Danzl, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Kentucky Medical Association, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM, Associate Clinical Professor of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School; Medical Director, WeCare Med, Inc
Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

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