Once a month for two years, a 55-year-old woman in Madrid had gone for acupuncture therapy using live bee stings. Apitherapy -- the medicinal use of bee hive products, including honey, pollen and bee venom -- was the woman's go-to treatment for stress and contractures, a tightening of her muscles that caused stiff joints.
Live bee sting acupuncture "is a technique that is becoming more widely available" around the world, said Dr. Ricardo Madrigal-Burgaleta, senior author of a case study describing the Spanish woman's experience and previously her doctor at Madrid's Ramon y Cajal University Hospital.
The case study was published in the current issue of the Journal of Investigational Allergology and Clinical Immunology.
The woman had shown no negative side effects to bee sting acupuncture, he said. In fact, her medical record recorded no history or mention of asthma, heart disease or allergies of any kind or to insects in particular.
But one day, during her monthly session, the woman began to wheeze and find it difficult to breathe after the first live bee sting.
Suddenly, she lost consciousness.
Rush to the hospital
After calling an ambulance, her worried acupuncturist administered methylprednisolone, a drug used to calm allergic reactions. Epinephrine, the usual treatment for extreme allergic reactions, was not available.
It took 30 minutes for the ambulance to arrive. By that time, the woman's systolic blood pressure had plummeted, and her heart was racing.
In transit to the hospital, the woman was given a double dose of epinephrine, infusions of saline solution, corticosteroids and antihistamines. Though her blood pressure and heart rate stabilized, she had become comatose and so required intubation.
At the hospital, an EKG, a chest x-ray and basic blood analyses all showed normal results for the still-comatose woman.
Later, a CT scan showed watershed stroke: cell death caused by blocked blood flow in the brain's "watershed" region, where two arteries supply blood.
In a matter of weeks, the woman died of multiple organ failure.
"This death could have been prevented if the adequate treatment strategies, risk management protocols, allergy trained staff and adequate installations had been available," said Madrigal-Burgaleta, who now works at Homerton University Hospital in London.
"At the moment, there's no validated way to know whether a patient is going to become sensitized to bee venom and develop a reaction," he said.
"But factors like repeated exposure to bee stings are decisive in enhancing the risk and severity," he said. "Normally, beekeepers are patients with more reactions and more treatment difficulties."
In many Asian countries and Eastern Europe, bee venom has been used as an official medical treatment for some time, according to a UN Food and Agriculture Organization bulletin. "In the Republic of China, bee venom therapy is combined with a knowledge of acupuncture by many hospitals and physicians," the bulletin states. Application of bee venom includes natural stings, subcutaneous injections, ointments, inhalations and tablets.
In the US, apitherapy is used to treat many illnesses and to alleviate pain, according to the American Apitherapy Society.
"Currently the most popular and well known uses of honey bee venom in the United States are for people suffering from Multiple Sclerosis and many forms of arthritis," the society noted on its website. Anecdotal reports suggest it as a treatment for infectious, autoimmune, cardiovascular, pulmonary and gastrointestinal diseases; neuropathic pain; and other chronic pain conditions.
Dr. Thomas B Casale, a professor of medicine at the University of South Florida, said it is "common" to develop a severe reaction to a bee sting after previously being non-allergic.
"Severe allergic reactions to insect stings can develop at any age, often following a number of uneventful stings," said Casale, who was not involved in the case study.
After exposure to insect venom, a non-allergic person can make the antibody responsible for allergies and become suddenly "sensitized," he explained. This can cause "a spectrum of allergic reactions," including local swelling, hives or "anaphylaxis and even death, as in this unfortunate patient," he said.
Since treatment is prompt use of intramuscular epinephrine, practitioners of bee sting acupuncture should be prepared and have epinephrine handy.
In the wild, the sting of a honeybee, rather than that of the more fierce yellow jacket, is more likely to lead to anaphylaxis, Casale said. And anyone undergoing bee sting acupuncture could become sensitized to the venom at any time.
"Stinging insects in the US account for about 50 deaths a year," he said.