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Case Study

Bilateral Ptosis in an Adult following Wasp Sting


with Spontaneous Recovery
Harpreet Singh*, Naresh Kumar*
Abstract
Neurological manifestations are rare with wasp sting. We report a case of a 45-year-old
male who presented with bilateral ptosis caused by wasp bite, which recovered
spontaneously within a week without using neostigmine.

Keywords: Wasp sting, Bilateral ptosis.

Introduction Case Report


Insects that sting belong to the order Hymenoptera, A 45-year male was bitten by wasp on his left pinna.
which includes bees, wasps, hornets, yellow jackets He developed mild swelling and tightening of skin at
and ants. Their venoms contain a wide array of the local site. He also developed drooping of bilateral
enzymes, peptides and amines which can cause local eyelids within a day. However, no other systemic
and systemic reactions. Neurotoxicity of wasp venom complaints were present. There was no history of
is rare but well-reported. Patient presenting with preceding diarrhea or episodic eyelid weakness. On
bilateral ptosis has been reported earlier which presentation, he had pulse rate of 86 beats/min,
recovered on neostigmine administration.1 respiratory rate of 14/min and blood pressure of
110/70 mmHg. There was swelling, redness and
Here, we present a case of wasp bite who presented tightness at and around the pinna of the left ear. He
with bilateral ptosis as the sole neurological was found to have bilateral ptosis and rest of the
manifestation and showed spontaneous recovery cranial nerve examination was normal (Fig. 1).
within a week.

Figure 1.Clinical photograph of patient showing Bilateral Ptosis at presentation

The deep tendon reflexes as well as sensory and total leukocyte count of 8440/mm3. His liver
neurological examination was normal. Rest of the function, kidney function, thyroid function and other
systemic examination was also unremarkable in this biochemical parameters were well within normal
case. Investigations revealed hemoglobin of 136 g/L limits.
*
Maulana Azad Medical College, New Delhi.
Correspondence to: Dr Naresh Kumar, 16/554, Joshi Road, Karol Bagh, New Delhi-110005. E-mail Id: drnareshmamc@gmail.com

© ADR Journals 2015. All Rights Reserved.


Singh H et al. J. Adv. Res. Med. 2015; 2(4)

Urine examination was normal. Repetitive nerve His ptosis started improving within 48 hours while he
stimulation test did not show any decremental was staying in the ward. Swelling and stiffness of
response. pinna also subsided. Patient was discharged in an
asymptomatic condition on the 7th day of admission
Patient was treated with injection Chlorpheniramine (Fig. 2). The patient did not develop any episode of
and Hydrocortisone. He was kept on close follow up. ptosis in follow up of 6 months.

Figure 2.Clinical photograph of the patient on the 5th day of admission showing recovery of ptosis

Discussion neurotoxicity is caused by venom kinins and


phospholipases. These mechanisms in combination
Different species of Hymenoptera produce venoms with the specific host conditions may be responsible
which are immunologically and biochemically distinct. for development of such an effect in these patients.
Direct toxic effects are mediated by mixtures of low-
molecular-weight compounds such as histamine, Patients can have pain, swelling, redness, tightness of
serotonin, acetylcholine, and several kinins. skin and wheal and flair reaction at the local site,
Polypeptide toxins in honeybee venom include which usually subsides within a few hours.
mellitin that damages cell membranes, mast cell Anaphylactic reaction can also occur if the reaction is
degranulation protein that causes histamine release, severe. Most deaths related to hymenoptera sting
apamin-the neurotoxin, and adolapin-the anti- result from anaphylaxis. The symptoms can arise after
inflammatory compound. Enzymes in venom include variable time from the sting ranging from 30 min to
hyaluronidase, acid phosphatase and phospholipases several weeks. Neurotoxicity of wasp venom is well-
A and B.2 There appears to be little cross-sensitization reported and kinins are the neurotoxic components of
between the venoms of honeybees and wasps. The wasp venoms causing presynaptic block of cholinergic
neurotoxins that have been isolated from wasp transmission. Although rare, these neurotoxic
venom include badykinin-related peptides, manifestations include encephalitis, myelitis, optic
pompilidotoxins, philanthotoxins and neuropathy, myasthenia gravis, cerebral infarction,
microbracotoxins.3 Some of these toxins are insect- neuromyotonia, acute inflammatory
specific. polyradiculoneuropathy, autonomic disturbances,
etc.4
The pathogenesis of neurological manifestations of
wasp sting is not yet completely understood. It is said A syndrome mimicking ocular myasthenia gravis have
that multiple mechanisms may be responsible for been reported by Brumlik J in 1976 and Hira et al. in
development of neurological abnormalities. The 2005.5,6 In the first case the symptoms persisted for
proposed mechanisms include postsynaptic weeks and responded to anticholinergics and steroids.
neuromuscular blockade due to antigen-antibody In the second case, the patient had bilateral ptosis
complex formation similar to that of myasthenia and external ophthalmoplegia along with decreased
gravis and presynaptic blockade of cholinergic palatal movement. Initial repetitive nerve test showed
transmission caused by noncompetitive inhibition of decremental nerve response with stimuli which
choline uptake leading to direct neurotoxicity.4 Direct recovered after treatment with neostigmine. Bilateral

ISSN: 2349-7181 2
J. Adv. Res. Med. 2015; 2(4) Singh H et al.

ptosis with wasp sting was first reported from India in References
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Conflict of Interest: Nil

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