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Bees, Part 1: Characteristics, Reactions, and Management CLOSE ENCOUNTERS WITH THE ENVIRONMENT What’s Eating You? Bees, Part 1: Characteristics, Reactions, and Management MAJ Felisa S. Lewis, MC, USA; Laurie J. Smith, MD Bee stings are common in the United States. Classification and Characteristics of Bees We review the characteristics of bumblebees, Insects in the order Hymenoptera, meaning “mem- honeybees, and Africanized honeybees; the types brane wings,” have 2 sets of front and hind wings and pathophysiology of sting reactions; and the that are connected by a series of little hooks called medical management and prevention of bee hamuli. A constriction in the abdomen distinguishes stings. In part 2 of this series, we will discuss these insects from similar-looking insects, such as the use of venom immunotherapy, the diagnosis flies.5 The order is large and includes not only bees of systemic mastocytosis that initially presents as (family Apidae) but also wasps and hornets (family anaphylaxis, and the efficacy of immunotherapy Vespidae) and ants (family Formicidae).2,6 Although in patients with mastocytosis. there are many types of bees, only bumblebees (genus Cutis. 2007;79:439-444. Bombus) and honeybees (including the Africanized honeybee, genus Apis) are considered of medical importance and will be the only ones addressed in this s members of the order Hymenoptera, bees article. The female aculeate (Aculeata, a suborder of deliver a venom-producing sting with which Hymenoptera, referring to the stinging capabilities A many people have had personal experience. of these insects) can inject its venom from a gland With 0.5% to 3.0% of the US population consid- or sac (singularly or in pairs) through an ovipositor ered allergic to venomous stings,1,2 and an average (a long tapered structure on the posterior portion of of 48 reported deaths annually in the United States their body)(Figure 1). Venom is delivered by poste- (27.1% of all animal-related fatalities) attributed to rior stings, which generally are intended for defense insect stings,3,4 physicians should be familiar with the only. The injection usually causes immediate pain cutaneous and systemic reactions that can result from with a nonfatal injury, which conditions the stung such stings. Furthermore, it is important to know how individual to avoid these insects.7 to manage and prevent these injuries and to educate Bees are a familiar sight, with their distinc- patients on these matters. Although the focus of tive black and yellow striped bodies. Bumblebees this article is on bees, much of the information also are approximately 20 mm long and have broad applies to other stinging insects, such as vespids (eg, bodies, whereas honeybees are slightly smaller, at social wasps that, like bees, live in colonies). 15 to 20 mm long.8 It is impossible to distinguish Africanized honeybees from the European honeybees of the United States without adminis- tering behavioral or genetic tests.9 The bumblebee and honeybee species are distributed worldwide; Accepted for publication June 8, 2006. From the Department of Allergy and Immunology, Walter Reed the Africanized honeybee (a cross between several 7 Army Medical Center, Washington, DC. European honeybee species and the African species) The views, opinions, or assertions contained herein are the was introduced to South America in 1956 and spread private views of the authors and are not to be construed as to Central America and Mexico before arriving in official or as reflecting the views of the US Army, the US Navy, the south central United States in 1993.8,10-12 Most or the US Department of Defense. The authors report no conflict of interest. stings occur during temperate months (eg, spring, Reprints: MAJ Felisa S. Lewis, MC, USA, 231 Little Quarry Rd, summer) and in areas of the United States where the Gaithersburg, MD 20878 (e-mail: [email protected]). insects’ presence is high (eg, the South).11,13 VOLUME 79, JUNE 2007 439 Close Encounters With the Environment Figure not available online Figure not available online Figure 1. A honeybee injecting venom through its stinger. Photograph © Scott Camazine (http://www.scottcamazine.com/photos/BeeSting/). Because bees are social insects, they primarily sting when their nest is threatened. Bumblebees inhabit nests with up to 200 bees, whereas honeybees live in colonies of up to 100,000 mem- bers.7 Bumblebees build their nests in loose fibrous habitats that are close to the ground, such as grass Figure 2. An immediate reaction to a bee sting. Photo- clippings. Many honeybees live within man-made graph © Scott Camazine (http://www.scottcamazine.com hives; however, in the wild, they build their nests /photos/BeeSting/). in cavities of buildings or in hollow trees.5 The infamous reputation of the Africanized honeybee is well-deserved because of its readiness to attack in an urticarial plaque (Figure 2).18 If a biopsy of the defense of its nest, respond in numbers, and swarm lesion is performed, histopathology may show a and pursue its victims.7,14 Because bees are used neutrophil and lymphocyte infiltrate in the papillary in crop pollination and food production, they are dermis, with plasma cells, eosinophils, and histiocytes numerous. The large numbers and aggressive nature appearing later8 and extending down to the reticular of bees (particularly Africanized honeybees) make dermis.19 For nonallergic individuals, this reaction humans especially vulnerable.7 will disappear within hours and cause only minor The distinguishing feature of the domestic and discomfort.7 Individuals with an increased sensitivity Africanized honeybee sting is that the barbed ovi- to bee stings can develop local skin reactions greater positor and venom sac are eviscerated from the body than 5 cm in diameter7,8,13 up to 48 hours after the of the bee and remain embedded in the flesh of the sting (Figure 3). At the site of the sting, the wheal victim.7,8 The honeybee itself dies after a single may become papular, edematous, and indurated, and sting.8,15,16 The musculature between the venom may take up to 7 to 10 days to resolve.8,15,20 glands will continue to pump venom through the Allergic individuals can develop more generalized stinger if not promptly removed. Thus, the stinger reactions that can be classified as mild, moderate, or can embed itself deeper into the flesh, enabling severe,21 with symptoms usually presenting within 10 the venom to reach more sensitive tissue.7,8,17 In to 20 minutes after the sting.22 Mild systemic reac- honeybees, alarm pheromones produced by stingers tions may result in cutaneous symptoms, which differ evaporate and attract more bees to this vulnerable from large local reactions only in that they are not area.7,8 In contrast, bumblebee stingers do not detach, contiguous with the sting site.23 Moderate reactions so a single bee may sting numerous times.8,16 involve organs other than the skin. The stereotypical symptoms of an allergy—sneezing, itchy watery eyes, Local and Systemic Reactions generalized pruritus, and cough—all can occur. Other A bee sting is an instantly painful insult to the skin. symptoms may include gastrointestinal tract distress, The skin characteristically develops a raised red lightheadedness, headaches, fever, and muscle spasms, wheal with a central white punctum at the site of as well as difficulty breathing.8,16,24-26 injury, with erythema and edema confined to the With a full immunologic response, severe symp- immediate surrounding skin and sometimes forming toms of anaphylaxis can occur, including generalized 440 CUTIS® Close Encounters With the Environment urticaria, bronchospasm, and bronchoconstriction resulting in angioedema, cardiovascular collapse, and loss of consciousness.4,19,24 Anaphylactic shock and death, with multiorgan failure, can occur within 30 minutes to 1 hour after even a single sting.27 With increasing doses of venom, convulsions, myocardial Figure not infarction, acute renal failure,28 and stroke may occur. available online At a median lethal dose of 19 stings per kilogram (approximately 500 bee stings), late death may result.29,30 Symptoms can mimic anaphylaxis because of the overwhelming amounts of venom or severe hypoxia of the cardiovascular and central nervous systems. Myoglobinuria, hemoglobinuria, or acute Figure 3. Large local reaction. Photograph courtesy tubular necrosis also have been reported.9,28 of James Solomon, USDA Forest Service (http://www.forestryimages.org). Pathophysiology of Reactions Honeybee venom contains several components that The IgE venom-specific antibodies formed from prior are responsible for physiologic reactions in humans. sensitization (type 1 hypersensitivity) are the impe- About 50 mg of protein is injected with each sting.14 tus for the release of histamines, leukotrienes, and The enzymes phospholipase A2 (PLA2) and hyal- prostaglandins from mast cells and basophils. In a uronidase are the main allergens in the venom. PLA2 mild response, only cutaneous signs may occur. In induces immunoglobulin E (IgE) production during more severe reactions, these mediators cause an the initial sensitization. Subsequent introduction of increase in capillary permeability and peripheral PLA2 interacts with IgE that is affixed to mast cells vasodilation, leading to fluid sequestration, loss of and basophils, which results in the immediate release vascular tone, and hypotension. Anaphylaxis and of mediators that can cause the symptoms of anaphy- anaphylactoid shock, which are both forms of dis- laxis. Hyaluronidase aggravates these initial injuries tributive shock, result from this vascular leakage and by causing changes in cell membranes that allow the smooth muscle contraction. Disseminated intravas- other venom components (PLA2 and IgE) to propa- cular coagulation can cause a generalized hemor- gate their damage. rhage that contributes further to systemic collapse. Melittin is a protein in the bee sting that decreases Bronchoconstriction and the direct cardiotoxicity of cell permeability. It is responsible for the immediate the mediators can induce hypoxia and cause heart 8,25,36 pain felt when stung.
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