Clinic: Apoidea (Bees)

Allergic reactions to bee venom

Single stings in non-sensitised individuals are uncomplicated, accompanied by pain, redness and swelling, unless the sting occurs in the throat (risk of choking).

The main life-threatening risk stems from hypersensitation to bee venom.

Epidemiology, prevention and treatment see

Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, Senna G, Sheikh A, Tanno LK, Thong BY, Turner PJ, Worm M. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020 Oct 30;13(10):100472. PMID: 33204386; PMCID: PMC7607509. https://doi.org/10.1016/j.waojou.2020.100472
Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. J Allergy Clin Immunol Pract. 2025 Jan;13(1):17-23.Epub 2024 Aug 20. PMID: 39173970. https://doi.org/10.1016/j.jaip.2024.08.025
Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JNG, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy. 2020 Mar;75(3):535-545. Epub 2019 Jul 16. PMID: 31194889. https://doi.org/10.1111/all.13945

Toxic effects of bee venom

Severe systemic poisoning with extensive swelling, leading to fluid shifts and hypovolaemia, haemolysis, neurological deficits, myolysis and renal failure, is only to be expected following a large number of stings.

For an exemplary severe case series (Apis mellifera scutellata; "Killer" bees, Africanised honey bees) see Franca et al. (2019) below.

Examine for venom effects

Autopharmacological effects

Nausea, vomiting
Sweating
Urticaria, angiooedema
Arterial hypotension / hypovolaemic shock
Diarrhoea
Bronchospasm

Local Effects

Pain
oedema, extended swelling

Haematological effects

Bleeding
Haemolysis
leading to
- Arterial hypotension
- Pale sclera
- Oliguria, anuria (arterial hypotension / AKI)

Neurological effects

Various neurological signs & symptoms

Autonomic nervous system effects
Adrenergic effects (catecholamine release)?

Tachycardia, arrhythmia, arterial hypertension, myocardial damage.

Muscular effects

Generalized rhabdomyolysis:
- Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
- Bulbar and respiratory muscle weakness.
- Dark brown urine.
- Renal failure
- Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
- ECG: Signs of hyperkalaemia.

Cardiac Effects

Secondary to catecholamine release?

Renal effects

Acute kidney injury:
- Loin pain (lower back pain)
- Renal bed sensitive to percussion
- Haematuria, haemoglobinuria, myoglobinuria
- Oliguria (< 400 ml of urine / 24 h), anuria

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the bee is clearly specified and in accordance with accepted criteria.

	Autopharma- cological effects^a	Local effects^b	Haematological effects^c			Neurological effects^d	Musular effects^e	Cardiac effects^f	Renal effects^g
			Bleeding	Coagulopathy	Haemolysis
Apis mellifera scutellata (Franca et al. 2019)

^aAutopharmacological effects

Oedema, extended swelling (histamine release).

^bLocale effects

Oedema, swelling

^cHaematological effects

Bleeding (Franca et al. 2019).
Clotting times slightly increased (Franca et al. 2019).
Anaemia (haemolysis) (Franca et al. 2019).

^dNeurological effects Autonomic nervous system effects / adrenergic effect (catecholamine release)? (Franca et al. 2019).

Arterial hypertension

^eMuscular effects

Signs and symptoms of rhabdomyolysis (Franca et al. 2019).

^fCardiac effects

Secondary to catecholamine release (?) (Franca et al. 2019).

^eRenal effects

Primary toxic effect
Secondary to rhadomyolysis and arterial hypotension (Franca et al. 2019).

Other

hepatocellular necrosis (Franca et al. 2019).
ARDS/pulmonary oedema. Capillary leakage? Secondary to catecholamine release? (Franca et al. 2019).

Clinical management

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Systemic antibiotics: standard indications
WHO (2010)

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Comprehensive ABCDE approach

ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE and ABCDE approach: first module)

Allergic reactions

Obey BEE- specific features

see 'Species-specific envenoming pattern' above.

Key issues

Rapid cardiovascular collapse and prolonged hypotension
Haemolysis, bleeding
Respiratory failure
Rhabdomyolysis, hyperkalaemia and hypercalcaemia
Renal failure (secondary to rhadomyolysis and arterial hypotension; primary nephrotoxic component)

Specific treatment (antivenoms)

No antivenoms available.

Exemplary case serie (multiple stings)

Apis mellifera scutellata

("Killer" bees, Africanised honey bees)

Brazil

Franca et al. (1994)
5 cases with estimated numbers of stings from >200 (3/5) to >1,000 (2/5).
Identification: morphological 2/5; with the help of indirect criteria 3/5.

Signs and syptoms

Local effects
Extensive oedema of the skin.

Haemostatic and haemolytic effects
Haemorrhages, haemolysis.

Neurological effects
Arterial hypertension (autonomic nervous system effects / adrenergic effect (catecholamine release)?)

Muscular effects
Rhabdomyolysis.

Cardiac effects
Arterial hypertension, subedocardial infarction (secondary to catecholamine release?)

Renal effects
Acute renal failure (secondary to arterial hypotension and rhabdomyolysis)).

Other
Hepatocellular necrosis.
ARDS/pulmonary oedema (capillary leakage? Secondary to catecholamine release?).

Case fatality rate

3 of 5 reported patients. Death occurred within 22–71 h. Histopathology: ARDS, hepatocellular necrosis, acute tubular necrosis, focal subendocardial necrosis, DIC (Franca et al. 2019).

References

Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, Senna G, Sheikh A, Tanno LK, Thong BY, Turner PJ, Worm M. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020
França FO, Benvenuti LA, Fan HW, Dos Santos DR, Hain SH, Picchi-Martins FR, Cardoso JL, Kamiguti AS, Theakston RD, Warrell DA. Severe and fatal mass attacks by 'killer' bees (Africanized honey bees--Apis mellifera scutellata) in Brazil: clinicopathological studies with measurement of serum venom concentrations. Q J Med. 1994 May;87(5):269-82. PMID: 7938407. https://pubmed.ncbi.nlm.nih.gov/7938407/
Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. J Allergy Clin Immunol Pract. 2025 Jan;13(1):17-23.Epub 2024 Aug 20. PMID: 39173970. https://doi.org/10.1016/j.jaip.2024.08.025
Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JNG, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy. 2020 Mar;75(3):535-545. Epub 2019 Jul 16. PMID: 31194889. https://doi.org/10.1111/all.13945
WHO ABCDE Approach. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139