It was supposed to be a nice refreshing run along a country road.

On my return loop, about a mile from my house, I felt an insect fly into my mouth. I immediately coughed it out and was a little surprised when I saw that it was not just a regular house fly—it had some yellow stripes on it. Nonetheless, I was having a good run and didn’t feel like stopping to take a better look. “Even if it was a bee or a wasp,” I thought to myself as I kept running, “thank God I’m not allergic.”

Literally 30 seconds later, I started to feel intense pain in the back of my throat, much like a sore throat from hell. Granted, even though I am more out of shape now than I used to be, it started feeling like it was getting harder to breathe.

A few scenarios started running through my head:

1. If my throat closes, at least I’ll be by a bigger road soon and somebody will see me.
2. I wonder how long the paramedics will take to get to my rural house.
3. I’m not that far from home. I know I have a scalpel, a bougie, and an endotracheal tube somewhere.

I managed to get home and took a cursory look at the back of my throat. My posterior pharynx was quite erythematous, but most noticeably, my uvula was the size of my thumb (see Figure 1)! Thankfully I wasn’t having any other symptoms except throat pain and massive uvular edema. I drank a glass of cold water to see if it would help, but I was still in a lot of pain. I closely reexamined my uvula and noticed a small black foreign body that was embedded in the mucosa. I thought to myself, “Could that really be what I think it is?” I grabbed some tweezers, gave it a tug, and sure enough, out came a bee stinger with an attached empty venom sac (see Figure 2). I quickly decided it might be best to be in a health care environment in case things got worse. I threw Betadine, a scalpel, a bougie, and an endotracheal tube in the front seat of my car and drove to the hospital.

Figure 1 (left): Dr. Podolej’s uvula with the bee stinger embedded in the mucosa.
Figure 2 (right): The bee stinger with attached empty venom sac after removal.
Photos: Gregory Podolej, MD

The Buzz on Bee Stings

Hymenoptera are stinging insects that are grouped into three families: Apidae (honeybees, bumblebees), Vespidae (wasps, hornets, yellow jackets), and Formicidae (ants).¹ Bee stingers have microscopic barbs that keep the stinger buried in tissue. When the bee flies away, the stinger is avulsed (along with part of the abdomen), and the bee eventually dies. Therefore, bees can only sting once. Wasps, on the other hand, have smooth stingers that allow them to sting a victim several times.

Hymenoptera stings cause more deaths in the United States than any other envenomation. Reactions range from a local inflammatory response to full-blown anaphylaxis.² Bee stings to the oropharynx, especially the uvula, are exceedingly rare.^3,4 Clinicians should have increased suspicion of airway compromise and be exceedingly conservative in the management of oropharyngeal hymenoptera stings because even a local reaction can cause significant airway compromise. It is crucial to perform a careful pharyngeal exam, and it is prudent to remove the stinger if possible.

It is important to emphasize that any patient presenting with anaphylaxis, hypotension, bronchospasm, or tracheo-laryngeal edema (not from direct sting to the area, as in my case) should be referred for venom immunotherapy (VIT).⁵ This is also true of adolescents older than 16 who present with urticaria or angioedema.5 VIT has been effective in reducing the allergic response in subsequent venom exposures, which can be lifesaving.⁶

Case Resolution

I never ended up checking into the emergency department. After curbsiding one of my colleagues for a quick exam, I felt silly wasting their time. I thought to myself, “What would I do for a similar patient without anaphylaxis? Diphenhydramine, ranitidine, steroids, maybe epinephrine, and probably admission for observation?” I had a night shift later that evening and didn’t want to be admitted or receive any medications that would require my being observed.

My symptoms were stable. I worked my night shift without any symptoms except for a sore throat and a funny-sounding voice.

Needless to say, this experience could have been much worse. If I were allergic to bees, I don’t know that I would have made it home without airway collapse. I also don’t recommend the treatment option I chose. I know that emergency physicians are very stoic and wait until the last possible moment to seek treatment, but although we can manage almost any condition, I think it is equally important to know when to let someone help you.

Dr. Podolej is in the department of clinical emergency medicine at the University of Illinois College of Medicine at Peoria and a simulation and medical education fellow at the Jump Trading Simulation & Education Center in Peoria.

References

1. Viswanathan S, Iqbal N, Shanmugam V, et al. Odynophagia following retained bee stinger. J Venom Anim Toxins Incl Trop Dis. 2012;18(2):253-255.
2. Tome R, Somri M, Teszler CB, et al. Bee stings of children: when to perform endotracheal intubation? Am J Otolaryngol. 2005;26(4):272-274.
3. Smoley BA. Oropharyngeal hymenoptera stings: a special concern for airway obstruction. Mil Med. 2002;167(2):161-163.
4. Kraiwattanapong J. Uvula bee sting: a case report. Siriraj Med J. 2016;68(3):187-190.
5. Mikals K, Beakes D, Banks TA. Stinging the conscience: a case of severe hymenoptera anaphylaxis and the need for provider awareness. Mil Med. 2016;181(10):e1400-e1403.
6. Boyle RJ, Elremeli M, Hockenhull J, et al. Venom immunotherapy for preventing allergic reactions to insect stings. Cochrane Database Syst Rev. 2012;10:Cd008838.