Case Report Acta Cardiol Sin 2009;25:31-5

Manifestations Mimicking Acute Myocardial Infarction after Honeybee Sting

Ho-Pang Yang, Fu-Chung Chen, Chien-Cheng Chen, Thau-Yun Shen, Shih-Ping Wu and Yung-Zu Tseng

Acute myocardial infarction (AMI) due to arthropod envenomization has rarely been reported. Herein, we report a 65-year-old woman with clinical manifestations mimicking AMI and left ventricular wall motion abnormality after honeybee sting. The patient eventually recovered from her illness with normal left ventricular wall motion on echocardiogram and T wave inversion on electrocardiogram. We also review the literatures.

Key Words: Arthropod envenomization · Honeybee sting · Acute myocardial infarction · Echocardiogram

INTRODUCTION cause of honeybee sting half an hour before. Her past history was noted with only dyslipidemia. At emergency Acute myocardial infarction (AMI) due to honeybee room (ER), she complained of chest pain, cold sweating, sting is rare, and only a few authors have discussed the generalized flash and near fainting. Her vital signs were relationship between the sting, anaphylactic shock and blood pressure: 154/98 mmHG, heart rate: 125 bpm reg- myocardial infarction.1-4 The allergic reaction induced ular and respiratory rate: 20/min. Otherwise, there were by hymenoptera stings seems to have triggered inflam- no particular findings on physical examination. AMI matory mediator release and thus induced acute coronary was suspected by the presence of chest pain, electrocar- syndrome. Kounis syndrome is the concurrence of acute diogram (ECG) showing bigeminal ventricular prema- coronary syndrome with mast cell activation induced by ture contractions (VPC’s) and significant ST-segment el- allergic or hypersensitivity and anaphylactoid reactions.5 evation in leads V2-6 (Figure 1A), and high serum Takotsubo cardiomyopathy is a stress-induced cardiac creatine phosphokinase (208 U/L; normal value, 12-144 syndrome mimicking acute myocardial infarction.6,7 He- U/L), creatine kinase-MB (5.21 ng/ml; normal value, < rein, we report a case with clinical manifestations mim- 4.89 ng/ml) but normal serum troponin-I level (< 0.2 icking acute myocardial infarction following honeybee ng/ml; normal value, < 0.2 ng/ml). This patient had some sting and review the literature. risk factors for coronary artery disease, including old age, being postmenopausal, and dyslipidemia. Her fam- ily history was unremarkable for coronary artery disease CASE REPORT or any kind of venous and/or arterial thrombotic events. Emergency coronary angiography was performed imme- A 65-year-old woman was sent to our hospital be- diately and revealed a 60% stenosis with TIMI 3 flow in the distal right coronary artery (Figures 2A, 2B). We did not perform the ergonovine or acetylcholine challenge Received: November 7, 2007 Accepted: October 20, 2008 test for coronary artery vasospasm. The patient’s echo- Department of Cardiology, Show-Chwan Memorial Hospital, Chang- Hua, Taiwan. cardiogram showed apical akinesis with preserved left Address correspondence and reprint requests to: Dr. Ho-Pang Yang, ventricular ejection fraction (Figure 3A). No potential Department of Cardiology, Show-Chwan Memorial Hospital, No. 542, sources of cardiac emboli were detected by echocardio- Sec 1, Chung-Shang Rd, Chang-Hua, Taiwan. Tel: 886-4-725-6166 ext 81000; Fax: 886-4-726-8537; E-mail: [email protected] graphy. The patient’s serum lipid levels were as follows:

31 Acta Cardiol Sin 2009;25:31-5 Ho-Pang Yang et al.

Figure 1. Twelve-lead electrocardiograms. (A) One hour after sting, with begeminal VPCs and ST elevation in leads V2-6. (B) 36 hours after sting, with ST elevation and T-wave inversion in leads II, III, aVF and V2-6. (C) One month after sting, with only mild T-wave inversion in leads II, III and aVF, and symmetrical T-wave inversion in leads V2-6. total cholesterol, 156 mg/dL; low-density lipoprotein, ml) occurred about 20 hours later. She undertook medi- 109 mg/ dL; triglycerides, 35 mg/dL; and high-density cations including antiplatelet drug and low-dose beta lipoprotein, 84 mg/dL. The ECG of 36 hours after sting block. Her admission course was smooth, and she was (Figure 1B) displayed evolutional changes of ST-T wave discharged uneventfully five days later. About one after myocardial injury. The peak levels of serum CPK month later, the patient received ECG and echocardio- (1192 U/L; normal value, 12-144 U/L), creatine kinase- gram follow-up. The ECG (Figure 1C) revealed only MB (90.3 ng/ml; normal value, < 4.89 ng/ml) and serum symmetric T-wave inversion in leads II, III, aVF and troponin-I levels (24.8 ng/ml; normal value, < 0.2 ng/ V2-6. The echo (Figure 3B) showed no regional wall

Acta Cardiol Sin 2009;25:31-5 32 Manifestations Mimicking Acute Myocardial Infarction after Honeybee Sting

Figure 2. (A) Left coronary angiogram (LAO, cranial view) showed non-significant stenosis. (B) Right coronary angiogram (LAO view) showed a 60% stenosis with TIMI 3 flow in the distal right coronary artery.

Figure 3. (A) Echocardiogram (apical four-chamber view) on day one after sting showed apical akinesis. End-diastole on left side, end-systole on right.(B)Echocardiogram (apical four-chamber view) one month after sting showed reversible regional wall motion. End-diastole on left side, end-systole on right. motion abnormality and preserved left ventricular ejec- gland and delivering that toxin during biting or stinging tion fraction. act. Arthropods, such as spiders, scorpions, and hymeno- ptera (bees, wasps, yellow jacket) are found wordwide, and some of them are venomous animals. DISCUSSION Acute myocardial infarction occurs very rarely after an arthropod envenomization. There are a few cases of The term “enomous animals” is usually applied to a AMI due to bee or scorpion bites reported in the litera- creature capable of producing a poison in a secretory ture.1-4 In these patients, coronary arteries were normal

33 Acta Cardiol Sin 2009;25:31-5 Ho-Pang Yang et al. or non-significantly stenotic. Our case presented clinical mization. Our case showed such change. manifestations of AMI including chest pain and changes Transthoracic echocardiography showing regional in cardiac enzymes and ECG. The coronary angiogram in wall motion abnormalities (hypokinesia and akinesia) our case also showed non-significant stenosis, which is and left ventricular dysfunction after an arthropod enve- the same as in the cases in the literature review.1-4 How- nomization was reported.4 The stunned myocardium has ever, the exact mechanism of AMI caused by arthropod long been known as a prolonged postischemic LV dys- envenomization is unclear. function after brief myocardial ischemia and presents a Hymenoptera (bees, wasps) stings or bites are re- reversiable LV dysfunction.13 Abrough et al. reported sponsible for more deaths than those from all other poi- gradual normalization of wall motion abnormality in the sonous creatures. Systemic reactions after stings are usu- left ventricle and septum, and also complete restoration ally of immediate type. The most frequent clinical events of the systolic function in case with severe scorpion en- are hypotension, dyspnea, anaphylactic shock and an- venomation.14 The change in echocardiographic findings gioedema. There are several reports dealing with cardio- of our case is similar to that of above reported cases.4,14 vascular complications after hymenoptera stings.2,8 The Moreover, clinical, electrocardiographic, laboratory and important medical problem posed by hymenoptera stings echocardiographic findings in our case excluded the pos- is the development of anaphylaxis. Hypotension is a sibility of myocarditis or pericarditis. common manifestation, with vasodilation and decrease Two cases are described with the possible associa- of intravascular volume. Patients are usually hypotensive tion between hereditary thrombophilia and arthropod on admission, but a few were hypertensive2,8 as in our bite giving rise to AMI without any evidence of athero- case. Many pharmacologically active constituents of sclerotic heart diseases.4 The authors therefore recom- hymenoptera venoms have been isolated.9 All these sub- mend that patients presenting with AMI following an ar- stances can provoke ischemia and even myocardial in- thropod bite should be screened for any inherited throm- jury via profound hypotension or by increasing oxygen bophilia.4 Another two patients who were stung by wasps demands through direct inotropic and chronotropic ef- and honeybee, respectively, developed Kounis syndrome fects in the presence of compromised myocardial supply. as a consequence of allergic reaction.5 Kounis syndrome Electrocardiographic changes consistent with acute is the concurrence of acute coronary syndrome with mast myocardial ischemia or infarction, including ST depres- cell activation induced by allergic or hypersensitivity sion or elevation and even the appearance of pathologic and anaphylactic of anaphylactoid reactions. Q-waves, have been recorded in people after stings.2,8,10 Takotsubo cardiomyopathy (Takotsubo CM) is a Rhythm abnormalities such as supraventricular arrhy- novel cardiac syndrome characterized by transient and thmias, VPC’s, junctional rhythm and right bundle branch severe LV apical ballooning and basal hyperkinesias in block were also recorded during initial stages after the acute stage.6,15 Although Takotsubo cardiomyopathy sting.2,8,11 Animal studies of bee venom have shown that shows striking initial manifestations mimicking AMI, such ECG changes may be due to direct cardiotoxic ef- the minimal change of cardiac enzymes are not consis- fect. However, the mechanism is still not clear. tent with the extent of LV change in acute stage, and un- Laboratory abnormality indicating myocardial in- usual LV morphology was restored to normal, usually jury, such as elevated CPK and GOT, was noted in peo- within several weeks, in most cases.6,15 In patients with ple with wasp sting.2,8 High serum creatine kinase and Takotsubo CM, the ECG in acute stage shows concave creatine kinase-MB levels following arthropod enveno- ST-segment elevation, usually in leads V3-6, there is less mization were reported previously.2,12 Theriseinserum dynamic change for days, followed by T-wave inversion creatine kinase and creatine kinase-MB levels might be and resolved in approximately 2-3 weeks6,16 associated due to myocardial injury and/or rhabdomyolysis caused with QTc prolongation.16 Abnormal Q-wave and recipro- by extremely high sympathetic discharge. Elevation of cal changes are rarely seen.16 Our case has similar initial more specific marker for myocardial injury such as car- manifestation as seen in Takotsubo cardiomyopathy, but diac troponin I or T following arthropod sting indicates the changes in cardiac enzyme and dynamic change of direct or indirect myocardial injury caused by enveno- ECG were quite different from these of typical case.

Acta Cardiol Sin 2009;25:31-5 34 Manifestations Mimicking Acute Myocardial Infarction after Honeybee Sting

In conclusion, hymenoptera (bee) venom can cause Cardiology 2007;114:252-5. acute coronary syndrome by several pathogenetic mech- 6. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventric- anisms: release of allergenic proteins, vasoactive, in- ular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina flammatory, and thrombogenic peptides and amine con- Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll stituents (histamine, serotonin, bradykinin, leukotrienes, Cardiol 2001;38:11-8. thromboxane), which act on the coronary vasculature 7. Chen CK, Chen CY. Atypical takotsubo cardiomyopathy (tran- and induce coronary artery vasospasm and facilitate sient left mid ventricular ballooning syndrome). Acta Cardiol Sin platelet aggregation as well as thrombosis; direct cardio- 2007;24:212-6. toxic effect of the venom; and anaphylactic reaction. 8. Brasher GW, Sanchez SA. Reversible electrocardiographic chan- This sequence of events, compounded by thrombosis at ges associated with wasp sting anaphylaxis. JAMA 1974;229: 1210-1. the site of spasm, can precipitate AMI. In our case, the 9. Maguire JH, Spielman A. Ectoparasite Infestations and Arthro- findings mimicking acute myocardial infarction (includ- pod Bites and Stings, In: Harrison’s Principles of Internal Medi- ing clinical symptoms, dynamic changes of ECG, cardiac cine. New York: McGraw Hill 1988:2251. enzyme and regional wall motion) were noted after a 10. Sanghi S, Vyas V, Hakim A, et al. Reversible transmural inferior honeybee sting. But the exact mechanism of AMI after wall ischemia after honeybee sting. Indian Heart J 1997;49: hymenoptera sting is still unclear. It may be an atypical 79-89. type of Takotsubo cardiomyopathy. 11. Law DA, Beto RJ, Dulaney J, et al. Atrial flutter and fibrillation following bee stings. Am J Cardiol 1997;80:1255. 12. Brasher GW, Sanchez SA. Reversible electrocardiographic chan- REFERENCES ges associated with wasp sting anaphylaxis. JAMA 1974;229: 1210-1. 1. Gueron M, Stern J, Cohen W. Severe myocardial damage and 13. Braunwald E, Kloner RA. The stunned myocardium: prolonged, heart failure in scorpion sting: report of five cases. Am J Cardiol postischemic ventricular dysfunction. Circulation 1982;66: 1967;19:719-26. 1146- 9. 2. Levine HD. Acute myocardial infarction following wasp sting. 14. Abrough F, Ayari M, Nouira S, et al. Assessment of left ventricu- Am Heart J 1976;91:365-74. lar function in severe soorpion envenomation: Combined hemo- 3. Wagdi P, Mehan VK, Burgi H, Salzmann C. Acute myocardial in- dynamic and echo-doppler study. Int Care Med 1995;21:629-35. farction after wasp stings in a patient with normal coronary arter- 15. Chiou CS, Chang NC, Shih CM, et al. Takotsubo cardiomyopathy ies. Am Heart J 1994;128:820-3. associated with jet-lag syndrome in a Taiwanese elderly woman:a 4. Kayikcioglu M, Eroglu Z, Kosova B, et al. Acute myocardial in- case report and literature review. Taiwan Geriatr Gerontol 2006; farction following an arthropod bite: Is hereditary thrombophilis a 2:130-41. contributing factor? Blood Coagulation & Fibrinolysis 2006;17: 16. Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the stan- 581-3. dard 12-lead ECG in patients with ‘Takotsubo’ cardiomyopathy: 5. Kogias J, Sideris S, Anifadis S. Kounis syndrome associated with comparison with the findings of acute anterior myocardial infarc- hypersensitivity to hymenoptera stings. International Journal of tion. Circ J 2003;67:687-90.

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