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      A Case of Conjunctival Bee Sting Injury with Review of the Literature on Ocular Bee Stings

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          Abstract

          Patient: Male, 24

          Final Diagnosis: Bee sting conjunctival injury

          Symptoms: Eye pain • red eye

          Medication: —

          Clinical Procedure: Ablation of the bee sting

          Specialty: Ophthalmology

          Objective:

          Unusual clinical course

          Background:

          Ocular bee stings have been rarely described in the literature, and their management is controversial. A case of conjunctival bee sting with retention of the stinger for 48 hours is presented with a review of the literature on the complications and management of ocular bee sting injury.

          Case Report:

          A 22-year-old beekeeper presented to the Emergency Department with mild symptoms from a conjunctival bee sting that he had received 48 hours previously. The stinger was removed in the Emergency Department, and topical antibiotic and anti-inflammatory treatment with corticosteroid were given. There were no complications in this case. However, review of the literature has shown that although the outcome from ocular bee stings can be mild, as in this case, ocular bee stings can result in severe visual symptoms that require amniotic membrane transplant (AMT). Management commonly includes removal of the stinger and both topical and systemic treatment with corticosteroids. The main complications include cataracts, inflammation of the anterior chamber, optic neuropathies, and changes in ocular pressure.

          Conclusions:

          Ocular bee stings have been rarely described in the literature, and the management remains controversial. As this case has shown, removal of the stinger and the use of topical treatment with antibiotics and corticosteroids can prevent potentially serious complications that may affect vision. Early and regular follow-up with ocular imaging may be required when symptoms persist.

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          Most cited references46

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          Structure and biology of stinging insect venom allergens.

          Bees, fire ants and vespids cause insect sting allergy. These insects have unique as well as common venom allergens. Vespids, including hornets, paper wasps and yellow jackets, have common allergens. Bees and vespids have one common allergen with hyaluronidase activity; they also have unique allergens with different phospholipase activities. Fire ants and vespids have one common allergen, antigen 5 of unknown biologic activity. The common venom allergens with < 70% sequence identity have barely detectable levels of antigenic cross-reactivity. Possible uses of modified allergens for immunotherapy are described.
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            Unusual reactions to hymenoptera stings: what should we keep in mind?

            This review includes a variety of extremely rare and unusual hymenoptera sting (HS) circumstances with regard to sting localization, geographic region, massivity of multiple stings, and particularly related to clinical symptoms. Such reactions occur in a temporal relationship to HS (s), differ from typical allergic symptomatology, and sometimes need follow-up during many months. With respect to pathogenesis, the major mechanisms involved are toxic, autoimmune, and other delayed immunological ones. While delayed inflammatory symptoms of the nervous system are considered as delayed hypersensitization or autoimmune entities, generalized rhabdomyolysis and consecutive acute kidney injury is considered a toxic reaction, mostly induced by massive envenomation to wasps or "Africanized" bees. Hemorrhagic episodes of targeted organ (s) could be additional potential risk for acute kidney injury, while the bee venom-induced hemorrhage is proposed to be a nonimmune-mediated anaphylactic symptom. The hemodynamic involvement of vital organs and systems with hypoxia and hypovolemia together with simultaneous immunoglobulin E (IgE) sensitization are considered potential indications for venom immunotherapy. In contrast, patients who have experienced various complications with unknown or nonallergic mechanisms should be informed about the importance of epinephrine's use and additional measures on future sting avoidance. In conclusion, although unusual reactions are extremely rare, it is important to keep them in mind.
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              Bee sting of the cornea and conjunctiva: management and outcomes.

              To present the clinical features, management, and outcomes of 4 cases of bee sting injury to the cornea and conjunctiva. Clinical features, external photographs, treatment, and outcomes of 4 cases of ocular bee stings are presented. In 3 cases, the stinger of the bee was retained on the cornea, and in 1 case, it was retained on the conjunctiva. One of the 3 corneal sting patients was stung on the laser in situ keratomileusis flap margin, which resulted in a partial tear of the flap. Retained bee stings were removed immediately in all 4 cases, and topical antibiotics were applied with adjuvant treatment. All patients had good visual outcomes without severe complications at follow-up. Ocular surface bee stings with retained stingers are rarely reported. A potential triad of penetrating, immunologic, and toxic injury must be taken into consideration. Vision can be restored by early removal of the sting and topical medication.
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                Author and article information

                Journal
                Am J Case Rep
                Am J Case Rep
                amjcaserep
                The American Journal of Case Reports
                International Scientific Literature, Inc.
                1941-5923
                2019
                31 August 2019
                : 20
                : 1284-1289
                Affiliations
                [1 ]Department of Ophthalmology, Regional Hospital Center of Metz-Thionville, Mercy Hospital, Metz-Cedex, France
                [2 ]Institut Paris Descartes, Sorbonne Paris Cité, University Imagine Institute, Paris, France
                Author notes

                Authors’ Contribution:

                [A]

                Study Design

                [B]

                Data Collection

                [C]

                Statistical Analysis

                [D]

                Data Interpretation

                [E]

                Manuscript Preparation

                [F]

                Literature Search

                [G]

                Funds Collection

                Conflict of interest: None declared

                Corresponding Author: Jean-Marc Perone, e-mail: jm.perone@ 123456chr-metz-thionville.fr
                Article
                917592
                10.12659/AJCR.917592
                6735618
                31471535
                82d70127-6697-4987-9769-fb8b95db8dc3
                © Am J Case Rep, 2019

                This work is licensed under Creative Common Attribution-NonCommercial-NoDerivatives 4.0 International ( CC BY-NC-ND 4.0)

                History
                : 16 May 2019
                : 28 June 2019
                Categories
                Articles

                adaptation, ocular,bees,case reports,conjunctiva,cornea
                adaptation, ocular, bees, case reports, conjunctiva, cornea

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