What is the composition and potential effect of a bee sting on a patient with no known allergies or pre-existing medical conditions?

Bee Sting Composition and Effects

Bee venom consists primarily of melittin and phospholipase A2 (PLA2) as the most abundant protein components, along with other peptides and enzymes that induce local toxic reactions at the sting site in all individuals, with most patients experiencing only transient pain, swelling, and redness lasting hours to days. 1, 2

Venom Components

Bee venom is a complex mixture containing:

• Melittin: The predominant peptide component responsible for pain and local tissue damage 2
• Phospholipase A2 (PLA2): The second most abundant protein, contributing to inflammatory responses 2
• Additional enzymes and peptides: Present in lower concentrations but contributing to overall venom effects 2
• Hyaluronidase and other spreading factors: Facilitate venom distribution through tissues 2

Expected Clinical Effects in Non-Allergic Patients

Normal Local Reactions

Most insect stings cause transient localized reactions of little serious medical consequence, requiring no treatment. 1

• Pain, swelling, and redness at the sting site that typically resolve within hours to a few days 1
• Pruritus (itching) at the sting site 1
• These reactions occur due to direct toxic effects of venom components, not allergic mechanisms 3

Management of Normal Local Reactions

• Remove the stinger within 10-20 seconds if present by flicking or scraping (not grasping the venom sac, which injects additional venom) 1, 4
• Cold compresses to reduce local pain and swelling 5
• Oral antihistamines to reduce itching 5
• Oral analgesics for pain management 5
• No treatment usually required for minor reactions 1

Potential Complications to Monitor

Large Local Reactions (5-15% of population)

• Swelling extending beyond 10 cm diameter contiguous to the sting site 1, 6
• Progressive increase in size for 24-48 hours, taking 5-10 days to resolve 1, 6
• These are IgE-mediated allergic reactions, not simple toxic reactions 1
• Treatment includes antihistamines, cold compresses, and in severe cases a short course of oral corticosteroids 1, 5
• Antibiotics are usually not necessary - the swelling is inflammatory, not infectious 1, 5

Systemic Reactions (0.4-0.8% of children, up to 3% of adults)

Even in patients with no known allergies, systemic reactions can occur:

• Cutaneous: Generalized urticaria and angioedema 1, 6
• Respiratory: Bronchospasm, upper airway obstruction, laryngeal edema 1, 6
• Cardiovascular: Hypotension, shock, cardiac arrhythmias, coronary artery spasm 1, 6
• Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain 1
• Neurological: Seizures 1

Fatal sting reactions are associated with delayed administration of epinephrine - immediate intramuscular epinephrine 0.3-0.5 mg in the anterolateral thigh is the treatment of choice 1, 5, 4

Toxic Reactions from Multiple Stings

• Greater than 100 simultaneous stings can cause severe toxic reactions due to massive envenomation 1, 4
• Direct venom toxicity can be fatal, particularly in children, even without anaphylaxis 7
• Manifestations may be clinically indistinguishable from allergic reactions 1

Critical Pitfalls to Avoid

• Grasping the venom sac when removing a stinger injects additional venom - instead flick or scrape it away 1
• Treating allergic swelling as infection leads to unnecessary antibiotic use 5, 6
• Delaying epinephrine if systemic symptoms develop - antihistamines and corticosteroids are not substitutes for epinephrine in anaphylaxis 1, 6
• Assuming no risk in non-allergic patients - allergic reactions can occur even after many uneventful stings and at any age 1

Special Identification Features

Honeybees usually leave a barbed stinger with attached venom sac in the skin after stinging, though ground-nesting yellow jackets can also leave stingers, so stinger presence is not absolutely diagnostic of honeybee stings 1, 6