Cerebral Infarction As a Rare Complication of Wasp Sting

Cerebral Infarction as a Rare Complication of Wasp Sting

1 123 Payam Moein, MD and Ramin Zand, MD, MPH 1Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, United States (email: [email protected] 2Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania, United States 3Biocomplexity Institute, Virginia Tech, Blacksburg, Virginia, United States

Introduction Journal of Vascular and Interventional Neurology, Vol. 9 Vol. and Interventional Neurology, Journal of Vascular Wasps, bees, and hornets belong to the order of insects There were an expected swelling and redness at the sting called “Hymenoptera.” Millions of cases of Hymenop- site on the back of his right hand. tera stings happen every year around the world. Fre- quently, they are accompanied by local inflammatory The neurological examination was significant for mild reactions. Less commonly, victims develop severe sys- dysarthria, uncontrollable movement of the left hand temic allergic reactions presenting with hypotension or (alien hand syndrome), decreased sensation to touch, anaphylactic shock, generalized edema, respiratory fail- pain, and temperature as well as extinction to double ure, or even multiple organ failures. Although rare, neu- simultaneous stimulation in the entire left upper extrem- rological complications including stroke have been ity. We also noticed vertical and horizontal nystagmus as reported (Table 1). In this paper, we present a case of well as ataxic gait and impaired tandem gait, which, ischemic stroke 30 min after a wasp sting, and a system- according to the patient, were chronic symptoms secon- atic review of the literature. dary to his multiple sclerosis.

Case Presentation His initial blood and imaging workup including cell blood count, complete metabolic and coagulation panel, A 53-year old Caucasian man was stung by a wasp on lipid profile, hemoglobin A1c, cardiac enzymes, electro- his right hand while he was working in his garage. Ini- cardiogram, chest x-ray was unremarkable except for a tially, there was just local pain and inflammation without mildly elevated serum creatinine (1.89 mg/dl) and an any systemic reaction. Thirty minutes later, while he was elevated serum low-density lipoprotein (160 mg/dl) and sitting on a chair, he noticed that his left upper limb triglyceride (329 mg/dl). Initial head computed tomogra- became numb and started moving out of his control. He phy (CT) scan was negative for any acute finding. The presented to our emergency department. magnetic resonance imaging (MRI) study of the brain, obtained within 6 hours, showed two punctate diffusion Past medical history was significant for multiple sclero- lesions in the right frontoparietal area consistent with sis which was diagnosed in 2002 and has been inactive acute cerebral infarction (Figure 1). A magnetic reso- since, coronary artery disease with myocardial infarction nance angiography (MRA) of the head and neck was and angioplasty in 2012, hypertension, and hyperlipide- unremarkable. The Doppler ultrasonography of the mia. His home medication included daily lisinopril 20 lower extremities, transthoracic echocardiography and mg and intermittent use of daily aspirin 81 mg. He transesophageal echocardiography, and hypercoagulable denied any history of smoking or alcohol consumption. and vasculitis panel were all unremarkable. A 4-day Family history was negative for stroke. inpatient telemetry results did not show any atrial fibril- lation or other abnormal cardiac rhythm. In the emergency department, the examination revealed a slightly overweight man, afebrile, with normal blood He was prescribed aspirin 325 mg and atorvastatin 80 pressure and respiratory rate, and mild tachycardia with mg daily. The left-hand movement stopped soon after a normal level of consciousness. Lungs were clear to admission; however, there was a mild residual weakness auscultation and heart was regular rate and rhythm with in the left hand. The weakness was completely resolved no adventitious sounds. No carotid bruit was noted. within 4 days.

Table 1. Case Reports on Ischemic Stroke and Other Associated Neurological Manifestations Following Bee/ Wasp Bite Presentation Number of stings and Imaging findings Outcome Other complica- location / Time inter- tions val between sting and stroke symptoms Schiffman, et 57 years old with left 30–40 bee sting on MRI & CT – right occipital Partial improvement of Ischemic optic al.[1] homonymous hemianopia head, face, neck and ischemic infarct followed with visual field loss neuropathy, hem- followed by unresponsive- right arm / 2 days a large right temporo-occipital orrhagic stroke ness hemorrhagic infarct Crawley et al. 30-year old with anaphy- Single wasp sting / 36 CT – left occipital infarction Full recovery Anaphylaxis, res- [2] laxis and respiratory failure hours piratory failure after a wasp sting. Right homonymous superior quadrantanopia after 36 hours Riggs et al.[4] 52-year old with anaphylac- Single wasp sting / a MRI – diffuse bilateral hemi- Noto reported Seizure, anaphy- tic shock 2 min after a wasp few hours sphere stroke lactic shock sting followed by slurred MRA – complete right internal Journal of Vascular and Interventional Neurology, Vol. 9 Vol. and Interventional Neurology, Journal of Vascular speech and left hemiparesis carotid artery and near com- a few hours later plete left internal carotid artery occlusion Rajendiran et 25-year old with left hemi- Multiple bee stings on MRI – right parietal and basal Complete motor and None al.[5] paresis and transient visual head and neck / not ganglia infarct vision recovery in 8 loss reported months Wani et al.[6] 40-year old with right hem- >50 wasp stings entire MRI – multiple ischemic Vegetative state Anaphy- iparesis, and severe multi- body / 16 hours lesions in bilateral cerebral laxis, multior- organ dysfunction. hemispheres, pons, bilateral gan failure thalami, and left parieto-occipital region. Temizoz et al., 60-year old developed a left Multiple bees stings MRI – ischemic changes in the Residual hemiparesis None 2009[7] sided hemiplegia and dys- entire body / 2 hours frontal lobes, right temporopar- after three months arthria ietal area, and bilateral centrum semiovale Sachdev et al., 40-year old with left hemi- Single wasp sting on MRI – right ventral pons, and Complete motor recovery None 2002[8] plegia and right facial face / 10 hours right cerebellum infarction within 5 days. Some droop improvement of cerebel- lar function and dysarthria after two months Stalin Viswa- 59-year old with dysarthria, Multiple bees sting MRI – right MCA territory Complete resolution of Seizure nathan et al., left sided upper motor neu- entire body / 2 hours infarct dysarthria and cranial 2012 [9] ron facial nerve palsy, left nerve deficits with signif- hemiplegia and left conju- icant recovery from the gate gaze palsy left hemiplegia after two weeks J. MURRAY 36-year old with confusion Multiple yellow jackets Not reported several generalized con- Seizure, intracere- DAY, 1962[10] and right hemiplegia stings over the neck, vulsions and hemody- bral hemorrhage, face and arms / 15 namic instability within and death minutes few hours followed by decerebration, intracerebral hemorrhage, and death within 30 hours after the stings Mukund R. 8 years old with left hemi- Not reported CT: non-hemorrhagic infarcts resolution of encephalop- Orbital cellulitis, Vidhate et al., plegia and altered mental in left frontoparietal and bilat- athy and some improve- bilateral caver- 2011[11] status followed by right eral subcortical regions and ment in left hemiplegia nous sinus throm- hemiplegia, ophthalmople- bilateral cavernous sinus with persistence right bosis gia, and partial left ophthal- thrombosis ophthalmoplegia 15 days moplegia MRI: infarcts in the left fronto- after admission parietal cortex, posterior limb of internal capsule, and right subcortical region Romano JT, et 34 months old with dysarth- Single yellow jacket’s CT – left putamen and caudate NR None al.,1989[12] ria and right hemiparesis sting on the inner side ischemic infarct of his upper lip / 4 days Angiography – left supracli- noid internal carotid artery occlusion Weeranun 64-year old with left hemi- Multiple bee stings on MRI: Large right MCA terri- Complete neurological Non ST-elevated Dechyapirom paresis and heart attack face, neck, chest, and tory ischemic stroke recovery within a week myocardial et al.,2010[13] upper extremities / 16 infarction hours De-Meing 71-year old woman with Multiple wasps entire Arteriography – total occlusion Partial recovery Infrarenal aortic Chen et al., left hemiplegia followed by body / 24 hours of the infrarenal aorta Two artery occlusion 2004[14] paraplegia. weeks later, CT – right MCA territory infarction

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Figure 1. Diffusion-weighted image (a) and T2-FLAIR (B) brain MRI showed two punctate ischemic lesions in the right frontoparietal.

Discussion stroke in the cases of wasp sting to the head and neck area [4]. We found 13 other case reports of ischemic stroke following wasp or bee sting in a systematic literature Our patient’s presentation was consistent with “Alien review on articles published prior to July 2015 in hand syndrome” that can occur in patients with stroke. PubMed and Google Scholar with the following search Although our workup did not show a definite etiology, topics: “bees or wasps” and “stroke or cerebral infarc- the etiology of his small diffusion defect in the right tion” (Table 1). Age at onset ranged from 34 months to frontoparietal cortex was probably embolic. Neverthe- 71 years old. Twenty percent of cases had anaphylactic less, the patient had some risk factors for stroke includ- shock preceding their stroke. The time interval between ing a history of hypertension, hyperlipidemia, and acute the sting and the stroke ranged from 15 min to 4 days coronary syndrome. The temporal relationship between with a median of 16 hours. On the brain MRI, findings the wasp sting and the development of neurological defi- were variable. Ischemic infarcts in the territory of mid- cits is likely related. Since no hypotension or allergic dle cerebral artery were commonly reported. Almost reaction was noted in our patient and he was stung only half of the patient recovered completely within 4 days to on his hand, it is unlikely that the stroke was related to 8 months. One patient developed intracerebral hemor- the retrograde intense activation of the superior cervical rhage and died. One patient developed multi-organ fail- sympathetic ganglion or anaphylactic shock and hypo- ure and progressed to a vegetative state. There was one tension. We think that the direct vasogenic and thrombo- case of cavernous sinus thrombosis reported in an 8-year genic effect of the wasp sting was the most likely mech- old toddler. Eight cases had suffered from multiple anism leading to stroke in our case. stings. References Several pathophysiologies have been postulated in the development of stroke after wasp or bee stings. The 1. Schiffman JS. Bilateral ischaemic optic neuropathy and stroke after multiple bee stings. Br J Ophthal 2004;88:1596–1597. major mechanisms include hypotension and hypoxia 2. Crawley F, et al. Cerebral infarction: a rare complica- related to an anaphylactic reaction, enhanced platelet tion of wasp sting. J Neurol Neurosurg Psychiatry 1999 Apr;66(4): aggregation, thrombogenesis, or vasoconstriction 550–551. induced by the release of several inflammatory substan- 3. Riggs JE, et al. Acute and delayed cerebral infarc- ces after the wasp sting [1]. These substances include tion after wasp sting anaphylaxis. Clin Neuropharmacol 1994 Aug; serotonin (5-hydroxytryptamine), histamine, dopamine, 17(4):384–348. acetylcholine, bradykinin, leukotrienes, and thrombox- 4. Romano JT, et al. Wasp sting-associated occlusion of the supracli- noid internal carotid artery: implications regarding the pathogenesis ane [2,3]. Intense retrograde stimulation of the superior of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. cervical ganglion resulting in obstruction of the terminal 5. Rajendiran C, et al. Stroke after multiple bee sting. J Assoc Physi- internal carotid artery is also reported to be causing cians India 2012;60:122–124. 16

6. Wani M, et al. Multiple cerebral infarctions with severe multi-organ 11. Vidhate MR, et al. Bilateral cavernous sinus syndrome and bilat- dysfunction following multiple wasp stings. Ann Indian Acad Neu- eral cerebral infarcts: a rare combination after wasp sting. J Neurol rol 2014;17(1):125–127. Sci 2011;301(1-2):104–106. 7. Temizoz O, et al. Stroke due to bee sting. Neurologist 2009;15(1): 12. Romano JT, et al. Wasp sting-associated occlusion of the supracli- 42–43. noid internal carotid artery: implications regarding the pathogenesis 8. Sachdev A, et al. Wasp sting induced neurological manifestations. of moyamoya syndrome. Arch Neurol 1989 Jun;46(6):607–608. Neurol India 2002;50(3):319–321. 13. Dechyapirom W, et al. Concurrent acute coronary syndrome and 9. Viswanathan S, et al. Middle cerebral artery infarct following multi- ischemic stroke following multiple bee stings. Int J Cardiol ple bee stings. J Stroke Cerebrovasc Dis 2012;21(2):148–150. 2011;151(2):e47–e52.Arch Neurol. 1989;46(6):607–608. 10. Day JM. Death due to cerebral infarction after wasp stings. Arch 14. Chen DM, et al. Descending aortic thrombosis and cerebral infarc- Neurol 1962;7:184–186. tion after massive wasp stings. Am J Med 2004;116(8):567–569. Journal of Vascular and Interventional Neurology, Vol. 9 Vol. and Interventional Neurology, Journal of Vascular