Forensic Files by DP Lyle, MD
Q&A: Will Ingestion of Bee Venom Kill Someone Who Is Allergic to Bees?
Q: If a person is allergic to bee venom and the venom is ingested, would the person be likely to die? Would the venom show up on a tox screen at autopsy?
A: Bee venom is a protein toxin and would be digested by the acids in the stomach if swallowed. And once digested it would not likely cause an allergic reaction. However, an allergic reaction would happen once the venom contacted the buccal mucosa—big word for the lining if the mouth. This could cause an anaphylactic reaction and kill the victim.
Anaphylaxis is a rapid allergic reaction to some antigen. These antigens are typically foods, drugs, or insect venoms. Common foods are peanuts and shellfish; common drugs are penicillin and iodine, which is found in many radiographic dyes; and common insects are bees as in your story. There a myriad other foods, drugs, and bugs that can cause anaphylaxis in the allergic person.
This rapid immune (or allergic) reaction involves antigens (the food, drug, the bee venom, etc.) and antibodies, which are manufactured by the body and react to the specific antigen that they are directed against. This reaction is a critical part of our defense against bacteria and viruses. The body recognizes the antigen (virus, let’s say) as foreign and builds antibodies that will recognize and attach to the virus. This reaction attracts white blood cells (WBCs), which release chemicals that kill or harm the virus, which is then consumed by the WBCs and destroyed. This process is essential for each of us to survive in our bacteria and virus-filled world.
But, in allergic individuals, this reaction is rapid and massive and causes a release of large amounts of the chemicals from the WBCs and it is these chemicals that cause the problems. They cause dilatation (opening up) of the blood vessels, which leads to a drop in blood pressure (BP) and shock. They cause the bronchial tubes (airways) to constrict (narrow severely), which leads to shortness of breath, wheezing, and cough. This is basically a severe asthmatic attack and prevents adequate air intake and the oxygen level in the blood drops rapidly. The chemicals also cause what is known as capillary leak. This means that the tiny microscopic blood vessels in the tissues begin to leak fluids into the tissues. This leads to swelling and various skin lesions such as a red rash, hives (actually these are called bullae and are fluid-filled, blister-like areas), and what are called wheel-and-flare lesions (pale areas surrounded by a reddish ring). These are also called Target Lesions because they look like targets with a pale center and red ring.
In the lungs this capillary leaking causes swelling of the airways, which along with the constriction of the airways, prevents air intake. In the tissues it causes swelling of the hands, face, eyes, and lips. The net result of an anaphylactic reaction is a dramatic fall in BP, severe wheezing, swelling and hives, shock (basically respiratory and cardiac failure), and death.
Usually anaphylaxis onsets within minutes (10 to 20) after contact with the chemical, but sometimes, particularly with ingested foods, it may be delayed for hours—even up to 24 hours. With a bee sting it would begin in a matter of minutes. Bee venom in the mouth might take only a few minutes to instigate the reaction.
Your victim would suffer swelling of the tongue and face—particularly of the lips and around the eyes—as well as swelling of his hands. Hives and wheel-and-flare lesions would pop out over the skin. He would begin to gasp for breath and develop progressively louder wheezing. As the oxygen content of his blood began to drop he would appear bluish around his lips, ears, fingers, and toes. This would progress until his skin was dusky blue. He would sweat, weaken, and finally when his BP dropped far enough would lose consciousness, lapse into a coma and die. Unless treatment was swift and effect that is.
Untreated anaphylaxis leads to shock and death in anywhere from a very few minutes to an hour or more, depending upon the severity of the reaction and the overall health of the victim. Treatment consists of blood pressure (BP) and respiratory support, while giving drugs that counter the allergic reaction. BP support may come from intravenous (IV) drips of drugs called vasopressors. The most common would be Dopamine, Dobutamine, epinephrine, and neosynephrine. Respiratory support may require the placement of an endotracheal (ET) tube and artificial ventilation. The victim would then be given epinephrine IV or subcutaneously (SubQ) and IV Benadryl and steroids. Common steroids would be Medrol, Solumedrol, and Decadron. These drugs work at different areas of the overall allergic reaction and reverse many of its consequences. The victim could survive with these interventions. Or not. Your call.
If you decide that your victim will die, then at autopsy, the findings are non-specific. That is, they are not absolutely diagnostic that an anaphylactic reaction occurred. The ME would expect to find swelling of the throat and airways and perhaps fluid in the lungs (pulmonary edema) and maybe some bleeding in the lungs. He may also find some congestion of the internal organs such as the liver. He must however couple these findings with a history of the individual having eaten a certain food, having ingested or being given a certain drug, or having receives an insect bite or sting and then developing symptoms and signs consistent with anaphylaxis. And in the case of insects, such as the bee you are using, he may be able to find antibodies to the insect’s venom in the victim’s blood. Maybe not. So you can have it either way—yes he finds the antibodies or no he doesn’t.
D.P. Lyle, MD