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LETTER TO THE EDITOR
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 132-133

Pathophysiological mechanism of stroke secondary to bee sting


Department of Medicine, Federal University of Santa Maria, Santa Maria, Rio Grande do Sul, Brazil

Date of Submission12-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication21-Mar-2022

Correspondence Address:
Dr. Jamir Pitton Rissardo
Av. Roraima, 1000 - Camobi, Santa Maria 97105-900, Rio Grande do Sul
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injms.injms_6_22

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How to cite this article:
Rissardo JP, Caprara AL. Pathophysiological mechanism of stroke secondary to bee sting. Indian J Med Spec 2022;13:132-3

How to cite this URL:
Rissardo JP, Caprara AL. Pathophysiological mechanism of stroke secondary to bee sting. Indian J Med Spec [serial online] 2022 [cited 2022 May 24];13:132-3. Available from: http://www.ijms.in/text.asp?2022/13/2/132/340034



Dear Editor,

We read the article entitled “Cerebral Infarction following Bee Sting” in the esteemed “Indian Journal of Medical Specialities” with great interest. Balagopal et al. described a middle-aged man presenting with right hemiparesis related to a single honeybee sting over his neck.[1]

Allergic reactions at the site of stings such as rashes and localized edema are the most common manifestations of bee venom. In this context, neurological clinical manifestations were uncommonly reported in the literature. To be more specific, stroke was rarely depicted, and these reports are mainly based solely on clinical observations.

Herein, we would like to discuss the pathophysiological pathways of stroke secondary to bee sting [Figure 1]. It is worthy of mentioning that the mechanism may vary among different bee species and the individual genetic predispositions as well as the clinical management.
Figure 1: Schematic diagram of the pathophysiological mechanism associated with stroke secondary to bee sting. (CNS - Central nervous system)

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After a bee sting, the venom activates some inflammatory mediators such as acid phosphatase, histamine, hyaluronidase, mast cell degranulating peptide, melittin, and phospholipase A2.[2] These chemical substances in the bloodstream can lead to systemic vasodilation due to increased vascular permeability and decreased heart rate. Therefore, the decreased cerebral perfusion could cause a cerebrovascular event.

Another possible mechanism is related to an overactivation of the sympathetic nervous system. In neuro-anatomical studies, it was found that some individuals could have a dense sympathetic innervation of the distal internal carotid artery by the superior cervical ganglion.[3] Furthermore, it is worthy of mentioning that vasopressors such as epinephrine are released during the stressful situation of a bee sting or even due to the venom poison chemical characteristics. In this way, in predisposed subjects, a honeybee sting could lead to a significant decrease in cerebral blood flow, causing cerebral hypoxia.

In the literature, there are some case reports of hypertensive intracerebral hemorrhage related to bee stings.[1] In these individuals, the pathological mechanism could be a combined pathway of inflammatory mediation and excessive sympathetic nervous system activation.

Interestingly, some patients have a stroke without abnormalities in systemic blood pressure.[4] Hence, we postulated that the bee venom could promote blood clotting causing ischemic stroke. This can be supported by the fact that bee stings can increase serum levels of thromboxane and cysteinyl-leukotrienes.[5] It is noteworthy that these two chemical compounds may cause platelet aggregation, hypercoagulability, and disturbed cerebral blood flow.

In sum, we have five possible major causes of cerebral ischemia that are hypotension, hypertensive hemorrhage, hypoxia, vascular thrombosis, and cerebral embolism. The proposed mechanisms are peripheral vasodilation, direct central nervous system vasoconstriction, and blood clot formation. The distinction of the pathophysiological mechanism of stroke secondary to bee sting leads to a better comprehension of this uncommon pathology and possible development of therapeutic strategies of other triggers of stroke.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Balagopal K, Muraleedharan A, Koshy AG, Jacob JP. Cerebral infarction following bee sting. Indian J Med Spec 2021;12:95-7.  Back to cited text no. 1
  [Full text]  
2.
Jang S, Kim KH. Clinical effectiveness and adverse events of bee venom therapy: A systematic review of randomized controlled trials. Toxins (Basel) 2020;12:558.  Back to cited text no. 2
    
3.
Scott-Solomon E, Boehm E, Kuruvilla R. The sympathetic nervous system in development and disease. Nat Rev Neurosci 2021;22:685-702.  Back to cited text no. 3
    
4.
Abhishek BR, Velayutham SS, Jeyaraj KM, Sowmini PR, Kumar MS, Sarvanan SV, et al. Thrombolysis in ischemic stroke after bee sting: A rare scenario. Ann Indian Acad Neurol 2021;24:985-6.  Back to cited text no. 4
  [Full text]  
5.
Abd El-Wahed AA, Khalifa SA, Sheikh BY, Farag MA, Saeed A, Larik FA, et al. Bee venom composition: From chemistry to biological activity. Stud Nat Prod Chem 2019;60:459-84.  Back to cited text no. 5
    


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