Myasthenic crisis following multiple bee stings: A rare case of neuromuscular dysfunction triggered by hymenoptera envenomation

Abstract

Introduction

Hymenoptera stings which include stings from bees, wasps, hornets, and fire ants, typically cause minor local reactions. However, systemic responses, including anaphylaxis and rare delayed complications, can occur. One such rare complication is Myasthenia Gravis (MG), a neuromuscular junction disorder characterized by skeletal muscle weakness due to antibodies against acetylcholine receptors (AChR). We report a case of acute neuromuscular weakness resembling a myasthenic crisis shortly after multiple bee stings.

Case Presentation

A 64-year-old male with type 2 diabetes and a history of Lumbar IVDP, presented after being stung by approximately 200 bees. He initially complained of facial puffiness, limb swelling, and generalized itching. He was febrile, bradycardic, and had diffuse erythema and edema. Initial management included antihistamines, systemic steroids, and stinger removal. Twelve hours later, he developed nausea, vomiting, and sudden onset dysphagia, ptosis, and proximal muscle weakness. Shortly after, he became dyspneic and required ICU admission with ventilatory support. Laboratory investigations revealed elevated CPK (2468 mcg/L) and negative Anti-AChR antibodies. On clinical grounds, he was treated with pyridostigmine and emergency plasmapheresis, resulting in gradual neuromuscular improvement. Supportive care was continued, and he was subsequently weaned off ventilator and was tracheostomized.

Conclusion

This case illustrates a rare myasthenia-like crisis triggered by multiple bee stings. Although confirmatory electrophysiological and serological evidence was lacking, the clinical presentation and therapeutic response strongly suggested neuromuscular junction dysfunction. The sequential association of bee sting and the onset of myasthenia gravis is too close to suppose chance association. Lack of immunologic abnormality may suggest the same. Though few cases of wasp sting causing Myasthenia have been reported, bee sting leading to neurological symptoms are unheard of. Our case highlights the importance of anticipating as well as early recognition of such complications.