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Case Report
Acta Cardiol Sin 2009;25:31-5
Manifestations Mimicking Acute Myocardial
Infarction after Honeybee Sting
Ho-Pang Yang, Fu-Chung Chen, Chien-Cheng Chen, Thau-Yun Shen, Shih-Ping Wu and Yung-Zu Tseng
Acute myocardial infarction (AMI) due to arthropod envenomization has rarely been reported. Herein, we report a
65-year-old woman with clinical manifestations mimicking AMI and left ventricular wall motion abnormality after
honeybee sting. The patient eventually recovered from her illness with normal left ventricular wall motion on
echocardiogram and T wave inversion on electrocardiogram. We also review the literatures.
Key Words:
Arthropod envenomization · Honeybee sting · Acute myocardial infarction · Echocardiogram
INTRODUCTION
cause of honeybee sting half an hour before. Her past
history was noted with only dyslipidemia. At emergency
room (ER), she complained of chest pain, cold sweating,
generalized flash and near fainting. Her vital signs were
blood pressure: 154/98 mmHG, heart rate: 125 bpm regular and respiratory rate: 20/min. Otherwise, there were
no particular findings on physical examination. AMI
was suspected by the presence of chest pain, electrocardiogram (ECG) showing bigeminal ventricular premature contractions (VPC’s) and significant ST-segment elevation in leads V2-6 (Figure 1A), and high serum
creatine phosphokinase (208 U/L; normal value, 12-144
U/L), creatine kinase-MB (5.21 ng/ml; normal value, <
4.89 ng/ml) but normal serum troponin-I level (< 0.2
ng/ml; normal value, < 0.2 ng/ml). This patient had some
risk factors for coronary artery disease, including old
age, being postmenopausal, and dyslipidemia. Her family history was unremarkable for coronary artery disease
or any kind of venous and/or arterial thrombotic events.
Emergency coronary angiography was performed immediately and revealed a 60% stenosis with TIMI 3 flow in
the distal right coronary artery (Figures 2A, 2B). We did
not perform the ergonovine or acetylcholine challenge
test for coronary artery vasospasm. The patient’s echocardiogram showed apical akinesis with preserved left
ventricular ejection fraction (Figure 3A). No potential
sources of cardiac emboli were detected by echocardiography. The patient’s serum lipid levels were as follows:
Acute myocardial infarction (AMI) due to honeybee
sting is rare, and only a few authors have discussed the
relationship between the sting, anaphylactic shock and
myocardial infarction.1-4 The allergic reaction induced
by hymenoptera stings seems to have triggered inflammatory mediator release and thus induced acute coronary
syndrome. Kounis syndrome is the concurrence of acute
coronary syndrome with mast cell activation induced by
allergic or hypersensitivity and anaphylactoid reactions.5
Takotsubo cardiomyopathy is a stress-induced cardiac
syndrome mimicking acute myocardial infarction.6,7 Herein, we report a case with clinical manifestations mimicking acute myocardial infarction following honeybee
sting and review the literature.
CASE REPORT
A 65-year-old woman was sent to our hospital be-
Received: November 7, 2007 Accepted: October 20, 2008
Department of Cardiology, Show-Chwan Memorial Hospital, ChangHua, Taiwan.
Address correspondence and reprint requests to: Dr. Ho-Pang Yang,
Department of Cardiology, Show-Chwan Memorial Hospital, No. 542,
Sec 1, Chung-Shang Rd, Chang-Hua, Taiwan. Tel: 886-4-725-6166
ext 81000; Fax: 886-4-726-8537; E-mail: [email protected]
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Acta Cardiol Sin 2009;25:31-5
Ho-Pang Yang et al.
Figure 1. Twelve-lead electrocardiograms. (A) One hour after sting, with begeminal VPCs and ST elevation in leads V2-6. (B) 36 hours after sting,
with ST elevation and T-wave inversion in leads II, III, aVF and V2-6. (C) One month after sting, with only mild T-wave inversion in leads II, III and
aVF, and symmetrical T-wave inversion in leads V2-6.
total cholesterol, 156 mg/dL; low-density lipoprotein,
109 mg/ dL; triglycerides, 35 mg/dL; and high-density
lipoprotein, 84 mg/dL. The ECG of 36 hours after sting
(Figure 1B) displayed evolutional changes of ST-T wave
after myocardial injury. The peak levels of serum CPK
(1192 U/L; normal value, 12-144 U/L), creatine kinaseMB (90.3 ng/ml; normal value, < 4.89 ng/ml) and serum
troponin-I levels (24.8 ng/ml; normal value, < 0.2 ng/
Acta Cardiol Sin 2009;25:31-5
ml) occurred about 20 hours later. She undertook medications including antiplatelet drug and low-dose beta
block. Her admission course was smooth, and she was
discharged uneventfully five days later. About one
month later, the patient received ECG and echocardiogram follow-up. The ECG (Figure 1C) revealed only
symmetric T-wave inversion in leads II, III, aVF and
V2-6. The echo (Figure 3B) showed no regional wall
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Manifestations Mimicking Acute Myocardial Infarction after Honeybee Sting
Figure 2. (A) Left coronary angiogram (LAO, cranial view) showed non-significant stenosis. (B) Right coronary angiogram (LAO view) showed a
60% stenosis with TIMI 3 flow in the distal right coronary artery.
Figure 3. (A) Echocardiogram (apical four-chamber view) on day one after sting showed apical akinesis. End-diastole on left side, end-systole on
right.(B)Echocardiogram (apical four-chamber view) one month after sting showed reversible regional wall motion. End-diastole on left side,
end-systole on right.
motion abnormality and preserved left ventricular ejection fraction.
gland and delivering that toxin during biting or stinging
act. Arthropods, such as spiders, scorpions, and hymenoptera (bees, wasps, yellow jacket) are found wordwide,
and some of them are venomous animals.
Acute myocardial infarction occurs very rarely after
an arthropod envenomization. There are a few cases of
AMI due to bee or scorpion bites reported in the literature.1-4 In these patients, coronary arteries were normal
DISCUSSION
The term “enomous animals” is usually applied to a
creature capable of producing a poison in a secretory
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Ho-Pang Yang et al.
mization. Our case showed such change.
Transthoracic echocardiography showing regional
wall motion abnormalities (hypokinesia and akinesia)
and left ventricular dysfunction after an arthropod envenomization was reported.4 The stunned myocardium has
long been known as a prolonged postischemic LV dysfunction after brief myocardial ischemia and presents a
reversiable LV dysfunction. 13 Abrough et al. reported
gradual normalization of wall motion abnormality in the
left ventricle and septum, and also complete restoration
of the systolic function in case with severe scorpion envenomation.14 The change in echocardiographic findings
of our case is similar to that of above reported cases.4,14
Moreover, clinical, electrocardiographic, laboratory and
echocardiographic findings in our case excluded the possibility of myocarditis or pericarditis.
Two cases are described with the possible association between hereditary thrombophilia and arthropod
bite giving rise to AMI without any evidence of atherosclerotic heart diseases.4 The authors therefore recommend that patients presenting with AMI following an arthropod bite should be screened for any inherited thrombophilia.4 Another two patients who were stung by wasps
and honeybee, respectively, developed Kounis syndrome
as a consequence of allergic reaction.5 Kounis syndrome
is the concurrence of acute coronary syndrome with mast
cell activation induced by allergic or hypersensitivity
and anaphylactic of anaphylactoid reactions.
Takotsubo cardiomyopathy (Takotsubo CM) is a
novel cardiac syndrome characterized by transient and
severe LV apical ballooning and basal hyperkinesias in
acute stage. 6,15 Although Takotsubo cardiomyopathy
shows striking initial manifestations mimicking AMI,
the minimal change of cardiac enzymes are not consistent with the extent of LV change in acute stage, and unusual LV morphology was restored to normal, usually
within several weeks, in most cases.6,15 In patients with
Takotsubo CM, the ECG in acute stage shows concave
ST-segment elevation, usually in leads V3-6, there is less
dynamic change for days, followed by T-wave inversion
and resolved in approximately 2-3 weeks6,16 associated
with QTc prolongation.16 Abnormal Q-wave and reciprocal changes are rarely seen.16 Our case has similar initial
manifestation as seen in Takotsubo cardiomyopathy, but
the changes in cardiac enzyme and dynamic change of
ECG were quite different from these of typical case.
or non-significantly stenotic. Our case presented clinical
manifestations of AMI including chest pain and changes
in cardiac enzymes and ECG. The coronary angiogram in
our case also showed non-significant stenosis, which is
the same as in the cases in the literature review.1-4 However, the exact mechanism of AMI caused by arthropod
envenomization is unclear.
Hymenoptera (bees, wasps) stings or bites are responsible for more deaths than those from all other poisonous creatures. Systemic reactions after stings are usually of immediate type. The most frequent clinical events
are hypotension, dyspnea, anaphylactic shock and angioedema. There are several reports dealing with cardiovascular complications after hymenoptera stings.2,8 The
important medical problem posed by hymenoptera stings
is the development of anaphylaxis. Hypotension is a
common manifestation, with vasodilation and decrease
of intravascular volume. Patients are usually hypotensive
on admission, but a few were hypertensive2,8 as in our
case. Many pharmacologically active constituents of
hymenoptera venoms have been isolated.9 All these substances can provoke ischemia and even myocardial injury via profound hypotension or by increasing oxygen
demands through direct inotropic and chronotropic effects in the presence of compromised myocardial supply.
Electrocardiographic changes consistent with acute
myocardial ischemia or infarction, including ST depression or elevation and even the appearance of pathologic
Q-waves, have been recorded in people after stings.2,8,10
Rhythm abnormalities such as supraventricular arrhythmias, VPC’s, junctional rhythm and right bundle branch
block were also recorded during initial stages after the
sting.2,8,11 Animal studies of bee venom have shown that
such ECG changes may be due to direct cardiotoxic effect. However, the mechanism is still not clear.
Laboratory abnormality indicating myocardial injury, such as elevated CPK and GOT, was noted in people with wasp sting.2,8 High serum creatine kinase and
creatine kinase-MB levels following arthropod envenomization were reported previously.2,12 The rise in serum
creatine kinase and creatine kinase-MB levels might be
due to myocardial injury and/or rhabdomyolysis caused
by extremely high sympathetic discharge. Elevation of
more specific marker for myocardial injury such as cardiac troponin I or T following arthropod sting indicates
direct or indirect myocardial injury caused by envenoActa Cardiol Sin 2009;25:31-5
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Manifestations Mimicking Acute Myocardial Infarction after Honeybee Sting
Cardiology 2007;114:252-5.
6. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel
heart syndrome mimicking acute myocardial infarction. Angina
Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll
Cardiol 2001;38:11-8.
7. Chen CK, Chen CY. Atypical takotsubo cardiomyopathy (transient left mid ventricular ballooning syndrome). Acta Cardiol Sin
2007;24:212-6.
8. Brasher GW, Sanchez SA. Reversible electrocardiographic changes associated with wasp sting anaphylaxis. JAMA 1974;229:
1210-1.
9. Maguire JH, Spielman A. Ectoparasite Infestations and Arthropod Bites and Stings, In: Harrison’s Principles of Internal Medicine. New York: McGraw Hill 1988:2251.
10. Sanghi S, Vyas V, Hakim A, et al. Reversible transmural inferior
wall ischemia after honeybee sting. Indian Heart J 1997;49:
79-89.
11. Law DA, Beto RJ, Dulaney J, et al. Atrial flutter and fibrillation
following bee stings. Am J Cardiol 1997;80:1255.
12. Brasher GW, Sanchez SA. Reversible electrocardiographic changes associated with wasp sting anaphylaxis. JAMA 1974;229:
1210-1.
13. Braunwald E, Kloner RA. The stunned myocardium: prolonged,
postischemic ventricular dysfunction. Circulation 1982;66:
1146- 9.
14. Abrough F, Ayari M, Nouira S, et al. Assessment of left ventricular function in severe soorpion envenomation: Combined hemodynamic and echo-doppler study. Int Care Med 1995;21:629-35.
15. Chiou CS, Chang NC, Shih CM, et al. Takotsubo cardiomyopathy
associated with jet-lag syndrome in a Taiwanese elderly woman:a
case report and literature review. Taiwan Geriatr Gerontol 2006;
2:130-41.
16. Ogura R, Hiasa Y, Takahashi T, et al. Specific findings of the standard 12-lead ECG in patients with ‘Takotsubo’ cardiomyopathy:
comparison with the findings of acute anterior myocardial infarction. Circ J 2003;67:687-90.
In conclusion, hymenoptera (bee) venom can cause
acute coronary syndrome by several pathogenetic mechanisms: release of allergenic proteins, vasoactive, inflammatory, and thrombogenic peptides and amine constituents (histamine, serotonin, bradykinin, leukotrienes,
thromboxane), which act on the coronary vasculature
and induce coronary artery vasospasm and facilitate
platelet aggregation as well as thrombosis; direct cardiotoxic effect of the venom; and anaphylactic reaction.
This sequence of events, compounded by thrombosis at
the site of spasm, can precipitate AMI. In our case, the
findings mimicking acute myocardial infarction (including clinical symptoms, dynamic changes of ECG, cardiac
enzyme and regional wall motion) were noted after a
honeybee sting. But the exact mechanism of AMI after
hymenoptera sting is still unclear. It may be an atypical
type of Takotsubo cardiomyopathy.
REFERENCES
1. Gueron M, Stern J, Cohen W. Severe myocardial damage and
heart failure in scorpion sting: report of five cases. Am J Cardiol
1967;19:719-26.
2. Levine HD. Acute myocardial infarction following wasp sting.
Am Heart J 1976;91:365-74.
3. Wagdi P, Mehan VK, Burgi H, Salzmann C. Acute myocardial infarction after wasp stings in a patient with normal coronary arteries. Am Heart J 1994;128:820-3.
4. Kayikcioglu M, Eroglu Z, Kosova B, et al. Acute myocardial infarction following an arthropod bite: Is hereditary thrombophilis a
contributing factor? Blood Coagulation & Fibrinolysis 2006;17:
581-3.
5. Kogias J, Sideris S, Anifadis S. Kounis syndrome associated with
hypersensitivity to hymenoptera stings. International Journal of
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