Case Study

Bilateral Ptosis in an Adult following Wasp Sting

with Spontaneous Recovery
Harpreet Singh*, Naresh Kumar*
Abstract
Neurological manifestations are rare with wasp sting. We report a case of a 45-year-old
male who presented with bilateral ptosis caused by wasp bite, which recovered
spontaneously within a week without using neostigmine.

Keywords: Wasp sting, Bilateral ptosis.

Introduction Case Report

Insects that sting belong to the order Hymenoptera,
which includes bees, wasps, hornets, yellow jackets
and ants. Their venoms contain a wide array of
enzymes, peptides and amines which can cause local
and systemic reactions. Neurotoxicity of wasp venom
is rare but well-reported. Patient presenting with
bilateral ptosis has been reported earlier which
recovered on neostigmine administration.1
Here, we present a case of wasp bite who presented
with bilateral ptosis as the sole neurological
manifestation and showed spontaneous recovery
within a week.
A 45-year male was bitten by wasp on his left pinna.
He developed mild swelling and tightening of skin at
the local site. He also developed drooping of bilateral
eyelids within a day. However, no other systemic
complaints were present. There was no history of
preceding diarrhea or episodic eyelid weakness. On
presentation, he had pulse rate of 86 beats/min,
respiratory rate of 14/min and blood pressure of
110/70 mmHg. There was swelling, redness and
tightness at and around the pinna of the left ear. He
was found to have bilateral ptosis and rest of the
cranial nerve examination was normal (Fig. 1).

Figure 1.Clinical photograph of patient showing Bilateral Ptosis at presentation

The deep tendon reflexes as well as sensory and total leukocyte count of 8440/mm3. His liver
neurological examination was normal. Rest of the function, kidney function, thyroid function and other
systemic examination was also unremarkable in this biochemical parameters were well within normal
case. Investigations revealed hemoglobin of 136 g/L limits.
*
Maulana Azad Medical College, New Delhi.
Correspondence to: Dr Naresh Kumar, 16/554, Joshi Road, Karol Bagh, New Delhi-110005. E-mail Id: drnareshmamc@gmail.com

© ADR Journals 2015. All Rights Reserved.

Singh H et al.
Urine examination was normal. Repetitive nerve
stimulation test did not show any decremental
response.
Patient was treated with injection Chlorpheniramine
and Hydrocortisone. He was kept on close follow up.
Figure 2.Clinical photograph of the patient on the 5th day of admission showing recovery of ptosis
Discussion
Different species of Hymenoptera produce venoms
which are immunologically and biochemically distinct.
Direct toxic effects are mediated by mixtures of low-
molecular-weight compounds such as histamine,
serotonin, acetylcholine, and several kinins.
Polypeptide toxins in honeybee venom include
mellitin that damages cell membranes, mast cell
degranulation protein that causes histamine release,
apamin-the neurotoxin, and adolapin-the anti-
inflammatory compound. Enzymes in venom include
hyaluronidase, acid phosphatase and phospholipases
A and B.2 There appears to be little cross-sensitization
between the venoms of honeybees and wasps. The
neurotoxins that have been isolated from wasp
venom include badykinin-related peptides,
pompilidotoxins, philanthotoxins and
microbracotoxins.3 Some of these toxins are insect-
specific.
The pathogenesis of neurological manifestations of
wasp sting is not yet completely understood. It is said
that multiple mechanisms may be responsible for
development of neurological abnormalities. The
proposed mechanisms include postsynaptic
neuromuscular blockade due to antigen-antibody
complex formation similar to that of myasthenia
gravis and presynaptic blockade of cholinergic
transmission caused by noncompetitive inhibition of
choline uptake leading to direct neurotoxicity.4 Direct
ISSN: 2349-7181
J. Adv. Res. Med. 2015; 2(4)
His ptosis started improving within 48 hours while he
was staying in the ward. Swelling and stiffness of
pinna also subsided. Patient was discharged in an
asymptomatic condition on the 7th day of admission
(Fig. 2). The patient did not develop any episode of
ptosis in follow up of 6 months.
neurotoxicity is caused by venom kinins and
phospholipases. These mechanisms in combination
with the specific host conditions may be responsible
for development of such an effect in these patients.
Patients can have pain, swelling, redness, tightness of
skin and wheal and flair reaction at the local site,
which usually subsides within a few hours.
Anaphylactic reaction can also occur if the reaction is
severe. Most deaths related to hymenoptera sting
result from anaphylaxis. The symptoms can arise after
variable time from the sting ranging from 30 min to
several weeks. Neurotoxicity of wasp venom is well-
reported and kinins are the neurotoxic components of
wasp venoms causing presynaptic block of cholinergic
transmission. Although rare, these neurotoxic
manifestations include encephalitis, myelitis, optic
neuropathy, myasthenia gravis, cerebral infarction,
neuromyotonia, acute inflammatory
polyradiculoneuropathy, autonomic disturbances,
etc.4
A syndrome mimicking ocular myasthenia gravis have
been reported by Brumlik J in 1976 and Hira et al. in
2005.5,6 In the first case the symptoms persisted for
weeks and responded to anticholinergics and steroids.
In the second case, the patient had bilateral ptosis
and external ophthalmoplegia along with decreased
palatal movement. Initial repetitive nerve test showed
decremental nerve response with stimuli which
recovered after treatment with neostigmine. Bilateral
2
J. Adv. Res. Med. 2015; 2(4)
ptosis with wasp sting was first reported from India in
2003.1 In this case, ptosis was associated with other
neurological manifestation suggestive of cranial nerve
involvement. The patient was treated with
neostigmine. The use of neostigmine in that case
followed by recovery also supported the hypothesis of
neuromuscular junctional blockade.7
A 2-year-old girl presented with bilateral ptosis, the
sole neurological manifestation along with the local
symptoms. She was managed with oral
pyridostigmine and was left with only mild ptosis of
right eye on 8 weeks of follow up.4 However, our case
presented with only bilateral ptosis along with the
local symptoms and was not treated with neostigmine
or pyridostigmine. All the symptoms including ptosis
improved completely within a week. The
improvement in our case without use of neostigmine
may be explained by the lesser amount of toxin in the
bite. The present case can well be the first case of
wasp bite-induced ptosis with spontaneous recovery
without use of neostigmine or pyridostigmine.
Conflict of Interest: Nil
3 ISSN: 2349-7181
Singh H et al.
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