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Acute tubulointerstitial nephritis following hymenopteran stings
  1. S Ezhilnilavan1,
  2. P S Priyamvada1,
  3. B H Srinivas2,
  4. H Satish2,
  5. S Parameswaran1
  1. 1Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
  2. 2Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
  1. Correspondence to Dr P S Priyamvada, Department of Nephrology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India; priyamvadaps{at}gmail.com

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Introduction

Wasps and bees are insects that belong to the order Hymenoptera. Hymenopteran sting can lead to renal failure, secondary to acute tubular necrosis. Acute tubulo interstitial nephritis is an uncommon, perhaps underdiagnosed clinical manifestation resulting from delayed hypersensitivity reaction to the venom.

Case 1

The first patient, an elderly woman, sustained a single Indian wasp sting (Vespa affinis) on the left index finger. She noticed mild redness, swelling and pain over the finger. The patient herself removed the sting, and an indigenous remedy (turmeric paste) was applied to the area. There was no history of administration of any oral or parenteral medications following the sting. The patient had no previous comorbidities and was not on any other long-term medications. There was no previous history of stings as well. Five days later, the patient started noticing pedal oedema which gradually increased over a few days. Along with oedema, she also noticed a gradual reduction in the urine output. The patient was referred to our hospital on the 10th day after sustaining the sting. On admission, there was bilateral pedal oedema; no pallor, icterus, bleeding manifestations or rashes. Her blood pressure was 190/80 mm Hg, and the systemic examination was unremarkable. The blood urea nitrogen was 31.7 mmol/L, and creatinine was 1225.6 μmol/L. Abdominal imaging showed normal-sized kidneys.The other laboratory parameters are given in table 1.

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Table 1

Laboratory parameters

The patient was initiated on haemodialysis. A kidney biopsy was performed on the sixth day after admission. Kidney biopsy showed 14 glomeruli of which 7 were normal and 7 were sclerosed. Interstitium was edematous and widened with infiltration of dense inflammatory cells comprising lymphocytes, plasma cells and plenty of eosinophils (figure 1, arrows 1A-1D). There was no tubulitis or granuloma formation. Few eosinophil and occasional neutrophil cast were present in the tubules. The tubular epithelium appeared flattened and denuded. Blood vessels showed medial …

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