A 40-year-old healthy male, who is a farmer by occupation, presented with burning pain and swelling all over the upper part of the body following multiple wasp stings. When the patient was cycling and going to his village, the nest of the wasps fell down from the weak branch of a tree and by this, the wasps were disturbed and around 50 wasps attacked him at once and caused the above injury and later after 2 days of this incidence, the patient developed progressive decrease in urine output.
The patient did not have any other significant illness in the past including hypertension, or any history of nephrotoxic drug intake. Examination revealed a pulse rate of 110/min, blood pressure of 150/100 mm of Hg and had swollen and edematous scalp, left upper limb, and upper thorax. There were multiple sting marks over the head, neck, face and the left upper limb . Other systemic examination was clinically normal.
Investigations revealed a blood urea of 120 mg/dl, serum creatinine which rapidly worsened from 1.2 mg/ dl to 4.5 mg/dl over next three days, the hematocrit was 50% and platelet count was 1.32 lakhs/mm3. The urine was reddish brown colored and showed 3+ proteinuria and 100 of red blood cells (RBCs). Activated partial thromboplastin time (APTT) was prolonged (32 s with a control of 26 s). Bleeding and clotting time was normal. The rest of the biochemical analysis showed serum creatinine phospho kinase (CPK) of 1 10 000 IU/l, lactate dehydrogenase (LDH) of 5250 IU/l, AST 1450 IU/l, ALT 950 IU/l. Serum potassium was 6.0 meq/l, serum sodium 130 meq/l, serum calcium 9.0 mg/dl, serum phosphorous 6.2 mg/dl and serum uric acid 7.0 mg/dl. Serum bilirubin was 1.9 mg% and urine myoglobin assay was more than 1000 ng/ml. The ultrasound of the abdomen showed normal sized kidneys with normal echotexture and preserved corticomedullary differentiation. Liver was normal in size and echotexture.
The patient had progressively worsening renal failure and remained oliguric (250-300 ml/day) for 3 days , in spite of adequate hydration. Hence, the patient was initiated on intensive hemodialysis, and continued the antibiotics, antihistamines and corticosteroids till the signs of inflammation came down. The patient underwent eight sessions of hemodialysis. After about 2 weeks, the patient entered a diuretic phase and his urine output started improving and serum potassium, APTT, and liver function tests became normal. Three weeks later his renal functions gradually became normal (serum creatinine 1.1 mg/dl).
Showing deteriorating renal functions