Journal of Clinical & Experimental Nephrology

Letter to the Editor

I am a Chilean Physician, joining a nephrology team that work in a middle size town at Chilean south in both a public hospital named Victor Ríos Ruiz (CAVRR) Los Angeles Biobio Chile and San Sebastian University, a prestigious private university, with more than 30 years of medical education in our hospital [1].

Our team always want to do research choosing cases of interest for sharing with other medical communities, as the case on “Relapsing nephrotic syndrome with acute renal failure following a unique episode of multiple bee stings: A case report”, which has been recently published.

We were pleasantly surprised with the request for your journal to write a letter to the editor regarding our case report and satisfied of being considered for this honour.

Our case reported has revealed many lessons for our team, because we never faced a patient with so many bee stings before, more than 20 per each lower extremity with generalized edema and blown nephrotic syndrome, followed by quickly renal function impairment and a short-time renal replacement need of less than a month. By surprise, our patient never had another organs involvement specially lungs nor hemodynamically support needs during the acute disease immediately after the massive bites, ruling out rhabdomyolysis as the first chance, performing the renal biopsy in the meantime, using parenteral steroids first dreading a rapidly progressive course of the renal failure, considering the creatinine elevation in a few days and afterwards we started oral prednisone [2].

Receiving the biopsy report we realized that the pedicellar disease was almost 100%, adding extensive tubular involvement, which was probably the real reason of dialysis need, supporting the almost full recovery to his former renal function in a few weeks after tubular recovery [3].

Going further, the four relapses happened in these six years of follow-up were another challenge, companied by temporary renal disfunction in most of them, yet never needing dialysis again with excellent immunosuppression effect in every relapse, recovering baseline creatinine pretty soon after any of both drugs for treatment, steroids at the first two episodes or anticalcineurin after. Therefore, after the third relapse we owe to choose tacrolimus, because a recently diabetes diagnosis will turn the steroids use cumbersome, without differences in the speed of stopping nephrosis between both drugs, almost at the first two months of the prescription [4].

Moreover, we checked literature trying to find out more cases related to these stings, with little success, trying to find a probably reason for these frequent relapses, considering that the patient sold his apiaries after the first episode and had no contact neither with bees nor honey again. As we depicted in our paper, it was probably an allergic status triggered firstly by the massive bee bites and afterwards other allergens could initiate a similar reaction, producing the nephrotic syndrome relapse in a sensitized patient. Until nowadays, the patient is maintained in low dose of tacrolimus (0.05 mg per kg per day), to avoid another nephrosis reactivation [5].

In summary, we believe this almost seven years of renal survival allowed us to learn a very good point of the evolution this very peculiar patient.

Acknowledgements

Thanks for my team and our patient for give us the opportunity to learn more about this issue.

Conflicts of Interest

We have no conflicts of interest.

References

1. Osman UMA, Turfan S, Mohamud MFY (2024) Multi-organ dysfunction due to envenoming syndrome following a massive bee attack: A fatal case study and comprehensive literature review. Int Med Case Rep J 17: 353-357.

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2. Hughes RL (2019) A fatal case of acute renal failure from envenoming syndrome after massive bee attack: A case report and literature review. Am J Forensic Med Pathol 40: 52-57.

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3. Da Silva Junior GB, Vasconcelos Junior AG, Rocha AMT, de Vasconcelos VR, Fujishima JS, et al. (2017) Acute kidney injury complicating bee stings-a review. Rev Inst Med Trop Sao Paulo 59: e25.

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4. Bridi RA, Balbi AL, Neves PM, Ponce (2014) Acute kidney injury after massive attack of africanised bees. BMJ Case Rep 2014: bcr2013201381.

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5. Waziri B, Alhaji UI, Oduwale MA, Umar HI, Abdulmalik AM, et al. (2022) A rare concurrence: Bee venom associated acute tubular necrosis and acute interstitial nephritis. Oxf Med Case Reports 2022: omac026.

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