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LETTER TO EDITOR
Year : 2005  |  Volume : 59  |  Issue : 3  |  Page : 117-119
 

Quadriparesis following wasp sting: An unusual reaction


1 Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
2 Department of Medicine. Government Medical College & Hospital, Sector 32, Chandigarh, India

Correspondence Address:
Vikas Agarwal
Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
India
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DOI: 10.4103/0019-5359.15090

PMID: 15805684

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How to cite this article:
Agarwal V, DCruz S, Sachdev A, Singh R, Kapoor V. Quadriparesis following wasp sting: An unusual reaction. Indian J Med Sci 2005;59:117-9

How to cite this URL:
Agarwal V, DCruz S, Sachdev A, Singh R, Kapoor V. Quadriparesis following wasp sting: An unusual reaction. Indian J Med Sci [serial online] 2005 [cited 2014 Nov 25];59:117-9. Available from: http://www.indianjmedsci.org/text.asp?2005/59/3/117/15090


Sir,

A 30-year-old male presented with progressive generalized weakness of 3 hours duration. Fourteen hours earlier, he sustained single sting from a wasp on his nasal bridge. Five hours prior to weakness he received injection chlorpheniramine maleate 25 mg and dexamethasone 8 mg. There was no history of diarrhea, vomiting, abdominal pain, intake of diuretics, hypertension and similar episodes in past or in the family. Examination showed swollen nasal bridge, generalized hypotonia, muscle power grade 2 at the shoulders and hips, grade 3 at elbow, knee wrists and the ankles, generalized areflexia except preserved ankle jerks and no sensory deficit. He was normotensive and had respiratory rate of 24/minute and single breath count of 20. Investigations revealed hypokalemia (2.4 meq/l), serum chloride 110 meq/l, serum sodium 138 meq/l, and arterial blood pH 7.26, PaO2 98­ mmHg, PaCO2 32 mm Hg, HCO3-14 meq/l. Urine pH was 5.9 and anion gap was 14, confirming distal renal tubular acidosis (RTA). Hemogram, urinalysis, and liver and renal functions and ultrasonogram abdomen were normal. Urine porphobilinogen was negative. Nerve conduction study (NCS) revealed increased latencies of peroneal and tibial, median and ulnar nerves and absent F-waves in all 4 limbs [Figure - 1]. Weakness and areflexia recovered completely within 16 hours following potassium and sodium bicarbonate supplementation. NCS 13 days later, revealed normalization of latencies and F-waves [Figure - 2]. Hypokalemia did not recur during 12 months of follow-up and therapy with oral sodium bicarbonate.

Wasp sting generally cause transient self-limiting local reactions. Unusually, serum sickness, vasculitis, encephalitis, peripheral or facial neuropathies, optic neuritis and myasthenia gravis,[1] acute ponto-cerebellar infarction,[2] have been reported. Etiology of these reactions is not known.

Quadriparesis in our patient was initially suspected to be due to acute inflammatory demyelinating polyneuropathy (AIDP) following hypersensitivity to the wasp sting. However, preservation of ankle jerks in a patient with otherwise areflexic flaccid quadriparesis aroused suspicion regarding the possibilities of other diagnoses such as periodic paralysis, porphyria, among others.[3] Whether wasp sting precipitated RTA in our patient was not clear.

Hypokalemia could be attributed to RTA or due to steroid usage. However, single bolus of dexamethasone causing hypokalemia is unusual, unless we hypothesize that his potassium stores were borderline because of subclinical RTA. Reversible electrophysiological abnormalities of sensory nerve have been reported patients with hypokalemic periodic paralysis.[4] However; our patient had AIDP on NCS, which favors an unusual reaction to the wasp sting.

 
 ¤ References Top

1.Levinsky NG. Fluid and electrolytes. Principles of Internal Medicine 13th edn. Isselbacher KJ, Braunwald E, Martin JB, Fauci AS, Kasper DL, Wilson JD (Editors). New York: Mcgraw-Hill; 1994, p.242-53  Back to cited text no. 1    
2.Sachdev A, Mahapatra M, D'Cruz S, Kumar A, Singh R, Lehl SS. Wasp sting induced neurological manifestations. Neurol India 2002;50:319-21.  Back to cited text no. 2    
3.Goel D, Singhal A. Importance of ankle jerk in acute flaccid paralysis. J Assoc Physicians India 2003;51:634-5.   Back to cited text no. 3  [PUBMED]  
4.Inshasi JS, Jose VP, van der Merwe CA, Gledhill RF. Dysfunction of sensory nerves during attacks of hypokalemic periodic paralysis. Neuromuscul Disord 1999;9:227-31.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]


Figures

[Figure - 1], [Figure - 2]

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