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CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 67-68

Immune-Mediated Membranoproliferative Glomerulonephritis Precipitated by a Bee Sting: A Case Report


1 Department of Nephrology, Yenepoya Medical College, Deralakatte, Mangalore, Karnataka, India
2 Junior Resident in Medicine, Yenepoya Medical College, Deralakatte, Mangalore, Karnataka, India

Date of Web Publication24-Apr-2015

Correspondence Address:
Santhosh Pai
Department of Nephrology, Yenepoya Medical College, Deralakatte, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2225-1243.155780

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  Abstract 

Insect stings belonging to Hymenoptera defined as wasps, yellow jackets, bees, or hornets by humans. Hymenoptera stings may result in a wide range of clinical spectra ranging from localized pain to systemic reaction and organ dysfunction and multiple organ failure. We report a patient with membranoproliferative glomerulonephritis (MPGN) which is immune secondary to a stimulus, which can also be added to the onset of secondary MPGN.

Keywords: Bee sting, renal biopsy,membranoproliferative glomerulonephritis


How to cite this article:
Pai S, Harischandra P, Jagadeesh T. Immune-Mediated Membranoproliferative Glomerulonephritis Precipitated by a Bee Sting: A Case Report. J Integr Nephrol Androl 2015;2:67-8

How to cite this URL:
Pai S, Harischandra P, Jagadeesh T. Immune-Mediated Membranoproliferative Glomerulonephritis Precipitated by a Bee Sting: A Case Report. J Integr Nephrol Androl [serial online] 2015 [cited 2019 Jul 15];2:67-8. Available from: http://www.journal-ina.com/text.asp?2015/2/2/67/155780


  Introduction Top


Insect stings belonging to Hymenoptera defined as wasps, yellow jackets, bees, or hornets by human usually result in unserious clinical pictures that go with pain. [1] On the it may cause death by anaphylaxis. However, Hymenoptera stings may result in a wide range of clinical spectra ranging from localized pain to systemic reaction and organ dysfunction and multiple organ failure. [2] We report a patient with membranoproliferative glomerulonephritis which is secondary to bee sting.


  Case Report Top


A 32-year-old man from Harihara was admitted to our hospital in January 2014 with pedal edema, puffiness of face, shortness of breath, since 1 week. He is a painter by occupation since last 10 years. He also recalls the symptoms had precipitated after a bee sting 10 days back. There was no history of diabetes, hypertension or any comorbid illness. No history of drug and food allergies.

On admission no history of fever, reduced urine output, no hematuria was noted. Edema of the face, and lower limbs was present with normal orientation. His pulse was 76/min regular rhythm BP of 130/70 mmHg, temperature 37.5 ° C. Urine analysis showed albumin 3+ with 4-6 RBC. Hematocrit was 37.3%, white blood cell count was 7900 with 33% neutrophils, 53% lymphocytes, 10% eosinophils, 4% monocytes, and 0% basophils; platelets were 360,000 and erythrocytes sedimentation rate was 45 mm/h. Blood urea was 37 mg/dL, serum creatinine 1.5 mg/dL, total serum protein 3.2 g/dL, albumin 1.3 g/dL, globulin 1.9 g/dL, cholesterol 305 mg/dL, triglycerides 197 mg/dL, LDL 235 mg/dL, and fasting sugar 86 mg/dL. 24-Hour total urine protein was 6168 mg/24 hours in 2400 mL. His complement level C3 was of 01 mg/dL and C4 of 0.7 mg/dL. His ultrasound abdomen showed normal sized kidneys with nil post voidal urine. His chest X-ray and electrocardiogram were normal. His weight on admission was 65 kg.

On admission he was commenced on frusemide and metalozone with a planned renal biopsy in view of normal kidney size, elevated lipids and gross proteinuria. Percutaneous renal biopsy was performed. Light microscopy revealed 11 glomeruli, 3 were obsolete. Among the viable glomeruli, there was diffuse endocappillary and mesanglial cell proliferation with partial obliteration of capillary lumen space. Capillary walls showed double-contoured basement [Figure 1] membranes focally. Interstitum showed granular and leukocytic casts and attenuated lining epithelium [Figure 2]. Vessels showed mild hyperplasia of tunica media and intima. On immunofluorescence two viable glomeruli were seen which showed diffuse granular deposit along with capillary and mesangium with IgG (3+), IgA (2+), IgM (2+), and C3 (2+). No extra glomerular deposits were seen. Based on the histological features, a diagnosis of membranoproliferative glomerulonephritis, immunoglobulin-mediated type, was made.
Figure 1: Capillary walls showing double contoured basement membranes focally

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Figure 2: Interstitum showing granular and leukocytic casts and attenuated lining epithelium

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The patient was also placed on omega 3 fatty acid supplements for managing dyslipidemia; he showed good improvement with diuretics, restricted salt intake; his weight reduced to 61 kg on discharge. He was placed on prednisolone, frusemide, low dose aspirin, pravastatin, omega 3 fatty acids and rabeprazole at discharge. He was initially started with 1 mg/kg/day dose of prednisolone. He improved dramatically and at 6 weeks his Serum Creatinine was 1.1 mg/dL with nil urine albumin. His prednisolone was tapered off in follow up.


  Discussion Top


We encountered a case of immune-mediated membranous nephropathy; clinically the patient presented with nephritic syndrome features. The pathogenic mechanisms responsible for the clinical sequelae following insect stings of the order hymenopterae (which comprises wasps and bees) include allergic reactions, rhabdomyolysis, hemolysis and direct tissue toxicity. Their venom contains protein toxins, biogenic amines, and enzymes that allow the toxins to spread. [3] The acute renal failure (ARF) due to wasp sting bites the toxic principles include active amines like histamine, serotonin, kinins, phospholipase A2, hyaluronidase, mellitin and apamine. [3],[4] Our patient had membranoproliferative glomerulonephritis probably due to direct nephrotoxicity.

In summary, we describe a patient with membranoproliferative glomerulonephritis which is immune secondary to a stimulus, which can also be added to the onset of secondary membranoproliferative glomerulonephritis.

 
  References Top

1.
Vachvanichsanong P, Dissaneewate P. Acute renal failure following wasp sting in children. Eur J Pediatr 2009;168:991-4.  Back to cited text no. 1
    
2.
Sharmila RR, Chetan G, Narayanan P, Srinivasan S. Multiple organ dysfunction syndrome following single wasp sting. Indian J Pediatr 2007;74:1111-2.  Back to cited text no. 2
    
3.
Habermann E. Bee and wasp venoms. Science 1972;177:314-22.  Back to cited text no. 3
    
4.
Sakhuja V, Bhalla A, Pereira BJ, Kapoor MM, Bhusnurmath SR, Chugh KS. Acute renal failure following multiple hornet stings. Nephron 1988;49:319-21.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2]



 

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