Abstract

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Bee stings are a common worldwide occurrence and most often present with local or systemic allergic reactions. There have been other documented rarer presentations where it has presented with acute coronary syndromes[i] and ischaemic optic neuropathy[ii]. There have been no documented cases of bee sting causing vasospasm in a cutaneous distribution; we present this case to show clinicians the varying signs of allergic reactions.

Case Report(s)

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A 12 year old previously healthy male, was admitted to the emergency department after having acute facial swelling following a bee sting to the foot. He had no past medical history of atopy, asthma or any previous allergic reactions. He had been stung by a honeybee 20 minutes before presentation. Despite having some facial swelling, he was haemodynamically stable with no airway compromise, so was bought in to the Emergency department for further assessment by the paramedics. On admission, he was pale but comfortable at rest. His blood pressure was 136/103, pulse was regular at a rate of 110 beats per minute. He was not dyspnoeic and his chest was clear. He had an erythematous patch on his right shoulder, which followed a vascular pattern. There was an absence of cutaneous veins resembling a lightning strike (Fig 1). A punctum was found on the dorsum of his right foot.

He was treated with chlorpheniramine and admitted for observation of his facial swelling and ongoing erythema on his right shoulder. Figure 1 shows the erythema with absence of the cutaneous venous system. Figure 2 shows the resolving erythema 5 hours later.

He had an otherwise uneventful recovery and was discharged the next morning.

Discussion

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Honeybees are from the Apidae family and release apitoxin upon insertion of their stinger into the skin, they are frequently found in forested areas. Bee stings can commonly present with a variety of symptoms ranging from local reactions (pain, swellings, cellulitis) to systemic allergic reactions ranging from mild (local urticarial rash), moderate (angiooedema, asthma) or severe (anaphylactic shock).

Several case reports have shown bee stings to have caused acute coronary syndromes, as the venom has the same physiological effect as histamine and thromboxane, which have vasoconstrictive properties[i].

This pattern has also been seen in victims of lightning strikes. Feathering sign, also known as (keraunographic marks, Lichtenberg’s flowers) have been said to be almost pathognomonic of lightning strikes[ii]. Surprisingly they are not true burns as there is no damage to the skin itself[iii]. One theory for this arborized cutaneous sign is that the transmission of static electricity along the superficial vasculature causes vasospasm.

Conclusion

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We have presented a case of an allergic reaction producing a “feathering sign” which is typically seen in lightning strikes. It is important to note that allergic reactions can present in a variety of ways without the typical features of an urticarial rash.

References

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[i] Johnson JL, Jackson CL, Angelini GD. Activation of matrix-degrading metalloproteinases by mast cell proteases in artheroslcerotic plaques.
[ii] Barthlome CW, Jacoby WD, Ramchand SC. Cutaneous manifestations of lightning injury. Arch Dermatol 1975;111:1466.
[iii] Gatewood MO, Zane RD. Lightning injuries. Emerg Med Clin N Am 22 (2004) 369-403

Source(s) of Funding

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none

Competing Interests

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none

Disclaimer

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