Clinical and biochemical profile of wasp sting patients in a tertiary care hospital
Authors
- Parash Ullah
Department of Gastroenterology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh - Habiba Kabir
Department of Internal Medicine, Bangladesh Medical University, Dhaka, Bangladesh - M. M. Jahangir Alam
Department of Medicine, Sylhet MAG Osmani Medical College, Sylhet, Bangladeshhttps://orcid.org/0009-0004-9767-2512 - Md. Shafiqul Bari
Department of Medicine, Dhaka Medical College, Dhaka. Bangladesh - Fazle Rabbi Chowdhury
Department of Internal Medicine, Bangladesh Medical University, Dhaka, Bangladesh
DOI:
Keywords
wasp sting, rhabdomyolysis, acute kidney injury, Vespa affinis
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Correspondence
Publication history
Received: 6 Jan 2025
Accepted: 12 July 2025
Published online: 24 July 2025
Responsible editor
Reviewers
Funding
None
Ethical approval
Approved by IRB of Sylhet MAG Osmani Medical College (No.somc/2014/700,
dated 1 Mar 2014).
dated 1 Mar 2014).
Trial registration number
Not applicableDeclaration
This article encompasses FCPS thesis of Dr Parash Ullah
Copyright
© The Author(s) 2025; all rights reserved
Published by Bangabandhu Sheikh
Mujib Medical University (currently, Bangladesh Medical University).
Published by Bangabandhu Sheikh
Mujib Medical University (currently, Bangladesh Medical University).
Abstract
Background: Wasp
stings and the resulting allergic reactions are common reasons for visiting the emergency
department. Stings can be fatal due to multi-system involvement. In our country, the impact of
massive wasp stings has been significantly underestimated and has not been systematically
investigated. This study aimed to identify the clinical presentations and biochemical profiles of
patients experiencing wasp stings in our context.
Methods: This case-series study was conducted at the Department of Medicine in Sylhet MAG Osmani Medical College Hospital, Sylhet, Bangladesh. The research involved species identification, based on photographic evidence, in conjunction with the patient’s history and informed consent. The study documented the socio-demographic history, details of the wasp bite, and related complications.
Results: Among the 30 patients studied, there were 22 males, and 8 females, mean (standard deviation) 36.5 (13.1) years. The average number of stings was 57.6 (114.7) (2 to 500 bites), and hospital arrival time ranged from 15 minutes to 8 days. All the patients experienced local pain, swelling, myalgia and rhabdomyolysis. Systemic complications, such as acute kidney injury (AKI), were observed in 20% of cases, with half of these requiring hemodialysis. Biochemically, elevated CPK, hyponatremia, and hyperkalemia were frequent. Most of the stings were attributed to Vespa affinis (21; 70%) and Vespa tropica (7; 23%).
Conclusion: Rhabdomyolysis was a universal finding in wasp sting cases. Delayed arrival to the hospital significantly increases systemic complications, with AKI emerging as the most common severe outcome. Early medical intervention is necessary to minimise these risks.
Key messages
Wasp stings are a relatively common but often underreported injury caused by
arthropods, with Vespa affinis and Vespa tropica being identified as the most common offenders.
Early detection and swift treatment can help minimise complications. To understand the burden of
this issue, countrywide species-specific epidemiological studies are required.
Introduction
The interface between humans and animals contributes significantly
to morbidity and mortality in humans. This interaction has intensified due to both natural and
human-induced changes in population dynamics, ecological factors, and behavior [1].
Wasps, which belong to the vespid subgroup within the order Hymenoptera, typically sting when
provoked, with incidents most frequently occurring in late summer and early autumn [2].
There are are over 6,000 wasp species worldwide, and wasp stings are common. In
the U.S., they account for 27.4% to 29.7% of animal-related injuries, with a yearly mortality rate
of 0.14 to 0.74 per million people [3,
4].
Insects that sting to
protect their colonies are part of the order Hymenoptera. The medically significant groups within
this order include Apoidea (bees), Vespoidea (wasps, hornets, and yellow jackets), and Formicidae
(ants). These insects deliver venom to their targets through stings.
Bees possess a barbed stinger, which they leave behind after
stinging, ultimately leading to their demise. In contrast, Wasps, hornets, and yellowjackets are
capable of stinging multiple times [5,
6].
Stinging incidents
involving honeybees and wasps are infrequent, with most deaths or serious cases resulting from fewer
than 10 stings, often due to anaphylactic shock. However, mass stinging can be life-threatening due
to the toxic effects of large amounts of venom being injected [5].
Wasp venom is a
complex mixture of proteins capable of impacting various tissues [7].
Stings from
wasps and bees can cause reactions ranging from mild symptoms like swelling and redness to severe
complications such as anaphylactic shock, rhabdomyolysis, acute kidney injury, heart attack, acute
liver failure, and encephalitis [8,
9,
10,
11].
Undetected anaphylactic reactions to Hymenoptera stings are a major cause of
sudden and unexpected deaths in young individuals, regardless of whether they have a history of
atopic conditions [12].
Fatalities from honeybee or wasp stings are rare and
usually result from Type I anaphylaxis linked to a single sting. Anaphylactic symptoms typically
occur within 10 minutes and do not correlate with the amount or number of stings [13].
Wasp stings are common in our country but often go unreported. This
study aims to examine the clinical and biochemical characteristics of sting victims and will also
address the lack of taxonomic research on local wasp species, providing a foundation for future
studies.
Methods
This case-series study was conducted in the Department of
Medicine at Sylhet MAG Osmani Medical College Hospital, Sylhet, between April 2014 and March
2015. The study population consisted of all patients admitted to the Department of Medicine who
met the inclusion criteria. The inclusion criteria were a recent history of wasp bite (the
offending agent will be confirmed by showing photographs or by bringing live or dead species)
and an age of 13 years and above, irrespective of gender. Patients poisoned by any other animals
or arthropods except wasp (Excluded by history and photograph of wasp), and patients with
mutism, stupor, and non-communicable conditions were excluded from the study. The wasp is
locally known as "Bolla" or "Bola". Some individuals have provided dead specimens of the Bolla.
A total of 30 cases were enrolled within the anticipated timeframe. Consecutive sampling was
employed as the sampling technique, and all available participants who met the criteria were
included until the desired sample size was reached. Data were collected using a semi-structured
questionnaire.
Data collection procedure
Initially, informed written consent was obtained from the patients. A brief history of the wasp
sting was then collected from the patient or their attendant. Once the offending wasp was identified
in accordance with the inclusion criteria, a thorough clinical examination was performed, and
necessary investigations were conducted. The investigation plan was based on the findings from the
clinical examination, including both local and systemic assessments. If there was any uncertainty
regarding species identification, the expertise of a zoologist was sought.
Statistical analysis
Data was processed manually using SPSS Version 16.0. Quantitative data were presented as
means with standard deviations. Qualitative data were reported in terms of frequency and
percentage, with comparisons conducted using Fisher's exact test.
Results
A total of 30 patients' data were analysed. The mean (standard deviation (SD)) age of the
respondents was 36.5 (13.1), and the age range was 13–70 years. The majority of affected
individuals were male. Patients were primarily managed with symptomatic care, focusing on
those who developed acute kidney injury (AKI). Out of six AKI cases, one required dialysis after
sustaining 180–200 bite marks, with initial creatinine levels at 3.2 mg/dL, peaking at 7.2
mg/dL, and creatine phosphokinase (CPK) levels reaching 800 U/L. A total of 20 dialysis cycles
were administered to normalise kidney function. The other cases were treated supportively,
utilising forced diuresis with furosemide, along with intravenous saline, sodium bicarbonate,
hydrocortisone, antihistamines, and antibiotics. The offender species was Vespa affinis.
Figure 1 Systemic
involvement of
patients with wasp bite (n=30)
Characteristics | Total (n=105) | Treated (n=55) | Untreated (n=50) | P |
Age (years) | ||||
≤24 | 52 (49.5) | 14 (25.5) | 38 (76.0) | <0.01 |
≥25 | 53 (50.5) | 41 (74.5) | 12 (24.0) |
|
Sex | ||||
Female | 43 (41.0) | 21 (38.2) | 22 (44.0) | 0.55 |
Male | 62 (59.0) | 34 (61.8) | 28 (56.0) |
|
Marital Status | ||||
Unmarried | 73 (69.5) | 33 (60.0) | 40 (80.0) | 0.03 |
Married/divorce/widow | 32 (30.5) | 22 (40.0) | 10 (20.0) |
|
Education | ||||
Up to secondary school | 51 (48.6) | 13 (23.6) | 38 (76.0) | <0.01 |
College completed and above | 54 (51.4) | 42 (76.4) | 12 (24.0) |
|
Occupation | ||||
Student/unemployed | 72 (68.6) | 36 (65.5) | 36 (72.0) | 0.34 |
Employed | 33 (31.4) | 19 (34.5) | 14 (28.0) |
|
Living area | ||||
Urban | 67 (63.8) | 36 (65.5) | 31 (62.0) | 0.83 |
Peri-urban/rural | 38 (36.2) | 19 (34.5) | 19 (38.0) |
|
All patients (30; 100%) experienced localised pain, swelling, and muscle pain, with all
showing signs of rhabdomyolysis. Six patients (20%) developed acute kidney injury (AKI).
Additional symptoms included vomiting (6; 20%), oliguria (6; 20%), hepatitis (4; 13.3%), and
dyselectrolytaemia (4; 13.3%). Rare cases included hemolysis (2; 6.7%), myocarditis (1,
3.3%), pulmonary oedema (1; 3.3%), and sepsis (1; 3.3%) (Figure 1).
Table 1
Relation of systemic
involvement (n=30) with the number of bite and time to hospital arrival
Characteristics | Number of bites | Lag period between bite to hospitalisation | ||
| <50 (n=21) | ≥50 (n=9) | ≤1 hour (n=10) | >1 hour (n=20) |
Rhabdomyolysis | 21 | 9 | 10 | 20 |
Acute kidney injury | 0 | 6 | 1 | 5 |
Haemolysis | 0 | 2 | 0 | 2 |
Myocarditis | 0 | 1 | 0 | 1 |
Hepatitis | 2 | 2 | 1 | 3 |
Pulmonary edema | 0 | 1 | 0 | 1 |
Septicaemia | 0 | 1 | 0 | 1 |
Dyselectrolytaemia (Hyponatremia) | 0 | 4 | 0 | 4 |
P | 0.01 |
| 0.04 |
|
Table 1 outlines a study of 30 patients, categorised by bite count (fewer than 50 bites, n=21; more than or equal to 50 bites, n=9) and time to hospital presentation (within 1 hour, n=10; after 1 hour, n=20). All patients experienced rhabdomyolysis, but complications such as AKI, hemolysis, myocarditis, pulmonary oedema, septicemia, and hyponatremia were exclusive to those with over 50 bites, with AKI affecting 6 out of 9 in that group. Hepatitis was equally observed in both groups (n=2 each). Delayed hospital arrival (more than 1 hour) correlated with increased systemic complications, including AKI (n=5), hemolysis (n=2), myocarditis (n=1), pulmonary oedema (n=1), septicemia (n=1), and hyponatremia (n=4), with a significant association noted (P=0.04). Table 2 summarises the results of various biochemical parameters. The mean (SD) SGPT level was 42.57 U/L (39.16 U/L), showing considerable variation among the individuals. The serum creatinine level had a mean (SD) of 1.67 mg/dL (2.04 mg/dl). CPK levels were significantly elevated, with a mean (SD) value of 1495.5 U/L (2676.2 U/L). Hyponatremia was common, with a mean (SD) value of 122.37 mmol/L (6.2 mmol/L). Serum potassium showed a mean (SD) value of 6.0 mmol/L (0.1 mmol/L). The study also identified the specific species of wasps responsible for the stings. Most cases involved 'Vespa affinis' (21; 70%), followed by 'Vespa tropica' (7; 2%), ‘Vespa mandarina’ (1; 3.3%) and ‘Vespa velutina’ (1; 3.3%) were rarely reported.
Table 2 Biochemical
parameters of patients with wasp bite (n=30)
Parameter | Mean (SD)a | Reference ranges |
Serum glutamic pyruvic transaminase | 42.6 (39.2) | (7.0–56.0) U/L |
Serum creatinine | 1.7 (2.0) | (0.6–1.2) mg/dL |
Creatine phosphokinase | 1495.5 (2676.2) | (20.0–200.0) U/L |
Sodium | 122.4 (6.2) | (135.0–145.0) mmol/L |
Potassium | 6.0 (0.1) | (3.5–5.1) mmol/L |
aSD indicates standard deviation | ||
Discussion
In this study, two-thirds of the patients fell within the 20 to
40 year age group. The findings are consistent with another study by Paudel et al. [14]
where the mean age was 35.5 years. Pérez Pimiento et al. reported a
mean age of 40.2 years, which differs slightly from our findings [15].
Males were
affected significantly more than females, and the findings are quite similar to those of other
studies [14,
15,
16].
This increased increased
incidence in males is attributed to their greater outdoor activity compared to females.
Interestingly, most of the symptoms were more common in males,
except for vertigo, hemolysis, and myocarditis. The cause of this gender difference remains
unclear. Witharana et al. observed that all patients (100%) experienced local pain, but
there was a notable difference in the occurrence of local swelling between studies. In our study,
local swelling was present in 100% of cases, compared to 86.7% in their study [16].
In this study, all patients developed myalgia and rhabdomyolysis, which were
more prevalent compared to the cases reported from Nepal, where these conditions affected 73% of
patients [14].
A fifth of the patients developed renal injury, including
oliguria and Acute kidney injury. This result is consistent with the findings of Xie
et al. in China, where they studied 1091 cases over 8 years from 2004 to 2011 [17].
In a study conducted in India, more than 85% of patients experienced severe
AKI and required dialysis [18].
However, in this particular study, only six
patients developed AKI, and just 1 of them needed dialysis. The incidence of liver injury,
hemolysis, and pulmonary oedema was also lower compared to the Chinese study. The variation
could be due to differences in wasp species, venom composition, and health-seeking behaviours of
people in different geographies [17].
In this study, the occurrence of abnormal biochemical parameters
was consistent with the findings of Xie et al. [17].
A notable
difference in CPK levels was observed in our study, with significantly higher rates (100% vs. 52%)
amongst the patients who developed AKI. However, elevated CPK or rhabdomyolysis alone may not
cause AKI, as other factors, such as wasp venom toxins and acute tubular necrosis, also contribute
to renal impairment [19,
20].
Systemic manifestations were more
commonly observed in patients with more than 50 stings, which aligns with the results reported by
Paudel B et al. [14].
Other complications, such as haemolysis,
myocarditis, hyponatremia, pulmonary edema, and septicemia, were consistent with Thiruventhiran et
al. and Xuan et al. studies [10,
13].
Most clinical
features and systemic manifestations were seen in patients who arrived at the healthcare centre
after one hour. Those treated within the first hour had minimal symptoms. The lag period between
sting and initiation of treatment directly correlates with patient outcomes, as was seen in a
Nepalese same [14].
The commonest species were Vespa affinis and Vespa tropica. Since
this is the first systematic study on species-specific envenomation in this area, no previous data
were available for comparison of the findings. Although a case report by Ullah et al.
from this region found the Vespa affinis species to be the commonest offender [19,
20].
Patients with multiple stings should be hospitalised
for hydration and urine alkalization to prevent AKI, as there is no antivenom available, and
treatment is mainly supportive. This study is the first in Bangladesh to systematically examine
wasp sting cases, providing valuable clinical, biochemical, and species-specific insights. It
highlights the correlation between delayed treatment initiation and severe complications like AKI
and offers practical recommendations for early management. A major limitation of the study was its
small sample size and absence of a control group of other insect bites. Patients often provided
species-specific information after viewing the album, which may lead to incorrect identification.
Moreover, the study was limited to hospitalised patients.
Conclusion
This study emphasises that stings from Vespa affinis and Vespa
tropica can cause serious complications like rhabdomyolysis and AKI, particularly when treatment
is delayed. The link between treatment timing and outcome severity underscores the importance of
prompt medical care and improved protocols for managing wasp envenomation. Quick treatment is
essential to save lives and reduce hospital stays. To prevent complications, avoid nephrotoxic
analgesics. Additionally, tracking specific wasp species is important for a better understanding
of biodiversity.
Acknowledgements
We would like to thank the Department of Medicine, Sylhet MAG Osmani Medical College Hospital,
Sylhet for their valuable support in conducting this study.
Author contributions
Conception or design of the work; or the acquisition, analysis, or interpretation of data for
the work: FRC. Drafting the work or reviewing it critically for important intellectual content:
PU, HK, FRC. Final approval of the version to be published: PU, HK, FRC, MMJA, MSB, FRC.
Accountable for all aspects of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and resolved: FRC, PU.
Conflict of interest
We do not have any conflict of interest.
Data availability statement
We confirm that the data supporting the findings of the study will be shared upon
reasonable request.
Supplementary file
None
