Question About a Bee Sting
Wednesday, March 12, 2008
Paul Auerbach, M.D.
A reader writes: "I was stung by bee on the palm of my hand and forefinger 6 weeks ago. My palm remains inflamed and swollen, which worsens as the day progresses; all joints remain tender. I have a small pebble-like knot under the skin approx 1/4" to 1/2" from where I was stung. I have been to 6 different doctors without receiving much explanation. I recently saw a hand specialist who diagnosed "trigger finger" brought on by the bee sting. Anyone ever heard of this? Is it possible that the tip of the stinger remained inside and migrated a bit from the sting site? Could the hard place be tissue forming around the stinger that may have remained inside? An E.R. nurse practitioner says it is possible that the stinger remains inside, however, my treating doctor says no way possible."
There are a number of possibilities here, related to the pathophysiology of a bee sting. Depending on the species of bee, part or all of the stinger may have been present in the wound immediately after the sting. For instance, a honeybee often leaves the stinger and attached venom sac in the wound. Sometimes the stinger is easily visible, revealed as a tiny dark splinter or speck. Other times, it is impossible to see without magnification. So, unless the sting site was very carefully inspected under magnification and no stinger seen, something may have remained in the wound. This is not usually the case, but it happens.
Bee venom contains a number of components that cause pain, redness, and swelling, all of which can be part of the initial toxic envenomation and subsequent inflammatory response. Depending upon how close the sting was to a tendon (and its sheath, within which it slides), it could have caused tenosynovitis, which could cause persistent pain on motion, and ultimately lead to some contraction of the finger, which might be diagnosed as a “trigger finger.”
The formation of a knot might represent inflammatory tissue solidifying into a scar around the initial puncture wound, which would be more likely if there was a residual “foreign body.” The remaining material doesn’t need to be a huge piece – even a microscopic speck is enough to fuel the process. The material under the skin would not migrate to a different location, unless it was within an open tract, which is highly unlikely. So, is it possible that a fragment of the stinger is still within the tissue? The answer is yes. It might be visible using an enhanced ultrasound technique, so that might be worth a try.
Tags: bee, bee sting, wilderness medicine, outdoor medicine, healthline
Labels: bee, bee sting, foreign body
4 Comments:
At Thu Mar 13, 10:42:00 AM 2008,
Jeremy Joslin, MD said…
Thanks for posting this very interesting case. Your blog really helps me learn through cases that I don't ordinarily see.
Dr. Auerbach, do you think this could be a Type 4 hypersensitivity reaction alone which is causing the drawn-out symptoms? Like you said, the inflammatory mediators alone could be causing all of these symptoms simply by mere proximity to all the fine hand structures.
While special ultrasonography would be a useful first line modality, if it's not available do you think MRI would be able to define the "knot" and give a hint as to which soft-tissue structure it is associated with?
To me it doesn't seem very likely that such a minute penetration of the skin could violate the nerve sheath.
Thanks again for bringing this up. It's very interesting to ponder.
At Mon Mar 16, 01:47:00 PM 2009,
Anonymous said…
I have type IV hypersensitivity involving antegens from insect bites and though the long drawn out symptoms are similar, the type IV with insect involvement also involves a massive influx of t cells and an overeaction of the immune system at the site if the sting. It starts out like a typical insecit bite reaction with itching and a little redness which anahisthamines help with. Within about 24 hours a hard center evolves at the center of the sting and a large localized reaction begins that can spread out 12 inches from the site, accompanied by itching, swelling and a hot to the touch feeling across the entire area. At this point, the topical and oral anahistamines do nothing and it take corticosteroids to resolve the reaction. Other than the delay there seems to be no other similarity.
At Thu May 21, 06:34:00 AM 2009,
G Torres said…
Just a quick question, is it harmful if some of the stinger stays under your skin? I was recently stung by a bee while on vacation and the stinger broke off with half remaining under my skin. My finger got swollen and now I can no longer see the stinger left behind. That was two days ago and my finger is still very swollen. I just don't know if I should be running to the doctor. I know the swelling could last for a week.
At Thu May 21, 12:07:00 PM 2009,
Paul Auerbach, M.D. said…
If a piece of the stinger remains under your skin, it will likely prolong the inflammatory response, and might (less likely) cause an infection. In either case, the symptoms would be redness, swelling, and pain, so it may be difficult to differentiate between a non-infectious inflammatory reaction and an infection. In the situation you have described, it is safest to have a trained medical professional look at your finger, to determine whether or not you should be started on an antibiotic, anti-inflammatory drug, both, or neither. It is a judgment call that should best be made by your doctor. If the stinger remains under your skin and everything clears up, it is not absolutely necessary to remove the fragment. But if it causes persistent symptoms, that may become the best thing to do.
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