Anaphylactic Shock Due to Bee Sting

Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: S. Randhawa, M.D., Fellow, LSU (Shreveport) Department of Allergy & Immunology

A 45-year-old AAM was taken to the ED with anaphylactic shock. He was working on his house when he was attacked by bees. He was stung twice and subsequently experienced generalized body hives and decrease in SBP to the 80s per EMS. The patient denied SOB, N/V or tongue swelling on admission. There was no prior exposure or allergic reaction. Benadryl 25 mg IV and bolus IV fluids were given by EMS.

PMH
Alcohol abuse, HTN, smoking

Medications
None

Physical examination
Drowsy but following commands
VS: BP 100/50, HR 101, RR 18, SpO2 93% on RA
HEENT: bilateral swollen upper eyelids, no tongue swelling, posterior oral pharynx visualized
Chest: CTA (B), no respiratory distress, no crackles or wheezing.
CVS: no murmurs, rubs or gallops, regular rate and rhythm.
Abdomen: Soft, NT, ND, + BS
Extremities: no c/c/e
Skin: generalized urticarial rash

What is the most likely diagnosis?
Anaphylactic shock

What would you do?
He was given:
Epinephrine 0.3 mg IM
Solumedrol 125mg IV
Benadryl 25 mg IV

What happened next?
The patient started to complain of sore throat. ENT consult was called who attempted to visualize the larynx with a fiberoptic scope but the patient was unable to cooperate due to exaggerated gag reflex.

His voice became hoarse, oxygen saturation decreased and he was re-examined by the ED physician who was not able to visualize the posterior pharynx. The anesthesiology team was called, etomidate and succinylcholine were used for paralysis, and ENT intubated the patient with a rigid laryngoscope on first attempt. Propofol infusion was started. ENT reported significant supraglottic swelling.

MICU team was called and the patient was admitted for mechanical ventilation and further treatment. Post-intubation chest X-ray showed appropriate ET tube placement. CBC and BMP were unremarkable. Urine toxic screen was positive for alcohol, and blood alcohol level was elevated.

The patient was on mechanical ventilation for 2 days and after successful extubation was transferred to a regular medical floor. His hospital course was complicated by delirium tremens due to alcohol withdrawal from which he recovered. He was discharged home with an EpiPen prescription and a follow-up appointment with an allergist.

Final diagnosis
Anaphylactic shock due to allergic reaction to bee sting

What did we learn from this case?
Drugs used for management of anaphylaxis are remembered by the mnemonic EASI:

Epinephrine IM
Antihistamines PO, IM
Steroids PO, IM, IV
Inhaled b2-agonists, if wheezing; IV fluids, if hypotensive


Figure 1. Mind map diagram of anaphylaxis.

References
Venom Allergy: A Short Review. V. Dimov, 08/2007.
Clinical review: ABC of allergies, Venom allergy. Pamela W Ewan. BMJ 1998;316:1365-1368.
Clinical review: ABC of allergies, Anaphylaxis. Pamela W Ewan. BMJ 1998;316:1442-1445.
Anaphylaxis. eMedicine, 07/2005.
Anaphylaxis to stings and bites. Robert J Heddle. MJA 2006; 185 (5): 290.

Published: 08/24/2007
Updated: 08/26/2008