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  1. Hymenopterans (Bees, Wasps and Ants)
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  3. Clinical entry: Vespidae (Wasps and Hornets)

Clinic: Vespidae (Wasps and Hornets)

Allergic reactions to vasp venom

Single stings in non-sensitised individuals are uncomplicated, accompanied by pain, redness and swelling, unless the sting occurs in the throat (risk of choking).

The main life-threatening risk stems from hypersensitation to vasp venom.

Epidemiology, prevention and treatment see

  • Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, Senna G, Sheikh A, Tanno LK, Thong BY, Turner PJ, Worm M. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020 Oct 30;13(10):100472. PMID: 33204386; PMCID: PMC7607509. https://doi.org/10.1016/j.waojou.2020.100472
  • Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. J Allergy Clin Immunol Pract. 2025 Jan;13(1):17-23.Epub 2024 Aug 20. PMID: 39173970. https://doi.org/10.1016/j.jaip.2024.08.025
  • Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JNG, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy. 2020 Mar;75(3):535-545. Epub 2019 Jul 16. PMID: 31194889. https://doi.org/10.1111/all.13945

Toxic effects of vasp venom

Examine for venom effects

Autopharmacological effects

  • Nausea, vomiting
  • Sweating
  • Urticaria, angiooedema
  • Arterial hypotension / hypovolaemic shock
  • Diarrhoea
  • Bronchospasm 

Local Effects

  • Pain
  • oedema, extended swelling

Haematological effects 

  • Bleeding
  • Haemolysis
    leading to
    • Arterial hypotension
    • Pale sclera
    • Oliguria, anuria (arterial hypotension / AKI)

Neurological effects

  • Various neurological signs & symptoms

Autonomic nervous system effects
Adrenergic effects (catecholamine release)?

  • Tachycardia, arrhythmia, arterial hypertension, myocardial damage.

Muscular effects

  • Generalized rhabdomyolysis:
    • Muscles pain and tenderness, painful on passive stretching, muscle stiffness, trismus
    • Bulbar and respiratory muscle weakness.
    • Dark brown urine. 
    • Renal failure
    • Laboratory: Generalized rhabdomyolysis: defined by a serum creatine kinase level > 10,000 U/l
    • ECG: Signs of hyperkalaemia. 

Cardiac Effects

  • Secondary effects?

Renal effects

  • Acute kidney injury:
    • Loin pain (lower back pain)
    • Renal bed sensitive to percussion
    • Haematuria, haemoglobinuria, myoglobinuria
    • Oliguria (< 400 ml of urine / 24 h), anuria
    • Uraemia (nausea, acidotic breathing, hiccups, pleuritic chest pain, encephalopathy) 

Species-specific envenoming pattern

The assessment of the envenoming pattern is based on the data from publication in which the identification of the vasp is clearly specified and in accordance with accepted criteria.

   Autopharma-
cological
effectsa		 Local
effectsb  
 		 Haematological effectsc Neurological
effectsd		 Musular
effectsee		 Cardiac
effectsf		 Renal 
effectsg
 Bleeding  Coagulopathy Haemolysis

Vespa orientalis

                  

Vespula germanica

                  

a Thrombocytopenia

b Secondary to rhadomyolysis and arterial hypotension

aAutopharmacological effects

  • Oedema, extended swelling (histamine release).

bLocale effects

  • Oedema, swelling
cHaematological effects
  • Bleeding.
  • Coagulopathy, thrombocytopenia
  • Anaemia (haemolysis).
dNeurological effects Autonomic nervous system effects / adrenergic effect (catecholamine release).
  • Arterial hypertension
eMuscular effects
  • Signs and symptoms of rhabdomyolysis.
fCardiac effects
  • Secondary to catecholamine release (?).
eRenal effects
  • Primary effects (Gong et al. 2019, Sitprija and Boonpucknavig 1972, Xie et al. 2013)
  • Secondary to rhadomyolysis and arterial hypotension. 
Other Hepatotoxic reaction

Clinical management

See also Clinical Management: hymenopterans

for advice on diagnosis (clinical, laboratory) and treatment (supportive).

Local treatment

Pain control
Tetanus prophylaxis
Standard wound care
Systemic antibiotics: standard indications
WHO (2010) 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Allergic reactions

Toxic effects of vasp venom

Obey Vasp- specific features

see 'Species-specific envenoming pattern' above.

Key issues

  • Rapid cardiovascular collapse and prolonged hypotension
  • Haemolysis, bleeding
  • Respiratory failure
  • Rhabdomyolysis, hyperkalaemia and hypercalcaemia
  • Renal failure (secondary to rhadomyolysis and arterial hypotension, primary nephrotoxic component)

Specific treatment (antivenoms)

No antivenoms available.

Exemplary case series (multiple stings)

Vespa orientalis

  • Gosh et al. (1988)
    1 case with 60 stings; 6-year-old child.
  • Sakhuja et al. (1988)
    5 cases with multiple stings (55, 46, 22, 63, 24 stings).
  • Weizman et al. (1985)
    1 case with 42 stings; 19-month-old child.

Vespula germanica 
Bousquet et al. 1984: 1 case with 175 stings.

Vespa affinis or Vespa tropica

  • Barss (1989)
    3 cases.

Signs & symptoms

Local effects
Vespa orientalis
Local pain and swelling (Gosh et al. 1988).

Vespula germanica
Local swelling and pain (Bousquet et al. 1984).

Haemostatic and haemolytic effects

Vespa orientalis
Haemolysis associated with anuria within a few hours after multiple stings (Gosh et al. 1988); haemolysis associated with acute renal failure (Sakhuja et al. 1988).
Vespula germanica
Icterus associated with oliguria, onset 57 h after multiple stings (haemolysis) (Bousquet et al. 1984).

Muscular effects

Vespa orientalis
Myalgia (Gosh et al. 1988); rhabdomyolysis associated with acute renal failure (Sakhuja et al. 1988).
Vespula germanica
Severe myalgia associated with oliguria, onset 57 h after multiple stings (Bousquet et al. 1984).

Renal effects

Vespa orientalis/Vespula germanica
Acute renal failure in the context of haemolysis and rhabdomyolysis (secondary renal failure and additional primary renal effect of the venom?) (Bousquet et al. 1984, Gosh et al. 1988).
Oliguria, onset 24–48 h after multiple stings, duration 11–22 days (Sakhuja et al. 1988).

Other signs & symptoms

Vespa orientalis
Hepatomegaly, encephalopathy (interpretation: hepatic coma - see below) (Weizman et al. 1985).

Morbidity

Acute renal failure, anaemia due to haemolysis (Bousquet et al. 1984, Gosh et al. 1988, Sakhuja et al. 1988).

Case fatality rate

2/3 (Barss 1989), 2/5 (Sakhuja et al. 1988).

Laboratory and physical investigations

Haemostasis
Vespa orientalis
Platelets 40,000/mm³ with no signs of disseminated intravascular coagulation (Gosh et al. 1988).
Platelets 40,000/mm³ with no signs ofdisseminated intravascular coagulation (Sakhuja et al. 1988).

Vespula germanica
Platelets 15,000/mm³ with no plasma coagulation defect (Bousquet et al. 1984).

Haemoglobin, haptoglobin, bilirubin
Vespa orientalis
Haemoglobin 6.6 g/dl within hours (Gosh et al. 1988).
Haemoglobin 4.4–7.6 g/dl, laboratory findings of haemolysis (Sakhuja et al. 1988).

Vespula germanica
Laboratory findings of haemolysis (Bousquet et al. 1984).

Myoglobinuria, CPK, LDH
Vespa orientalis
Laboratory findings of rhabdomyolysis (Gosh et al. 1988; Sakhuja et al. 1988: 2/5, in 3/5 this was not investigated).

Vespula germanica
Laboratory findings of rhabdomyolysis (Bousquet et al. 1984).

Creatinine, serum potassium
Vespa orientalis
Laboratory findings of renal failure (Gosh et al. 1988); (Sakhuja et al. 1988).

Vespula germanica
Laboratory findings of renal failure (Bousquet et al. 1984).

Renal biopsy
Vespa orientalis
Histologypathology: acute tubular necrosis with extensive necrosis of the tubular epithelium, regenerative foci and interstitial oedema, pigmented casts in the tubular lamina (Sakhuja et al. 1988).

Liver function
Vespa orientalis
Elevated serum transaminases and alkaline phosphatase(Sakhuja et al. 1988); in addition decreased prothrombin time, serum ammonia, arterial 248 mg% (normal range 40–60 mg%) (interpretation: hepatic coma stage C) (Weizman et al. 1985).

Liver biopsy
Vespa orientalis
Histopathology: centrilobular necrotic foci (Sakhuja et al. 1988). Microvesicular fatty infiltration and diffuse mitochondrial changes (Weizman et al. 1985).

References

  • Barss, P. (1989)Renal failure and death after multiple stings in Papua New Guinea. Ecology, prevention and management of attacks by vespid wasps. Med. J. Aust. 151: 659-663
  • Bousquet, J., G. Huchard, F. B. Michel (1984) Toxic reactions induced by Hymenoptera venom. Ann. Allergy 52: 371-374
  • Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, Geller M, Gonzalez-Estrada A, Greenberger PA, Sanchez Borges M, Senna G, Sheikh A, Tanno LK, Thong BY, Turner PJ, Worm M. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020 Oct 30;13(10):100472. PMID: 33204386; PMCID: PMC7607509. https://doi.org/10.1016/j.waojou.2020.100472
  • Gong J, Yuan H, Gao Z, Hu F. Wasp venom and acute kidney injury: The mechanisms and therapeutic role of renal replacement therapy. Toxicon. 2019 May;163:1-7. Epub 2019 Mar 14. PMID: 30880185. https://doi.org/10.1016/j.toxicon.2019.03.008
  • Gosh, K., S. Singh, B. J. G. Percira, S. C. Singhi (1988) Acute systemic toxic reactions caused by hornet stings. Indian Pediatrics 25: 796-798
  • Sakhuja, V., A. Bhalla, B. J. G. Pereira, M. M. Kapoor, S. R. Bhusnurmath, K. S. Chugh (1988) Acute renal failure following multiple hornet stings. Nephron 49: 319-321
  • Sitprija V, Boonpucknavig V. Renal failure and myonecrosis following wasp-stings. Lancet. 1972 Apr 1;1(7753):749-50. PMID: 4111226. https://doi.org/10.1016/s0140-6736(72)90267-x
  • Sturm GJ, Schadelbauer E, Marta G, Bonadonna P, Kosnik M. Risk Factors for Severe Sting Reactions and Side Effects During Venom Immunotherapy. J Allergy Clin Immunol Pract. 2025 Jan;13(1):17-23.Epub 2024 Aug 20. PMID: 39173970. https://doi.org/10.1016/j.jaip.2024.08.025
  • Stoevesandt J, Sturm GJ, Bonadonna P, Oude Elberink JNG, Trautmann A. Risk factors and indicators of severe systemic insect sting reactions. Allergy. 2020 Mar;75(3):535-545. Epub 2019 Jul 16. PMID: 31194889. https://doi.org/10.1111/all.13945
  • Weizman, Z., H. Mussafi, J. S. Ishay, Y. Shvil, K. Goitein, N. Livni, R. J. Deckelbaum (1985) Multiple hornet stings with features of Reye’s syndrome. Gastroenterology 89: 1407-1410
  • WHO ABCDE Approach. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2
  • WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139
  • Xie C, Xu S, Ding F, Xie M, Lv J, Yao J, Pan D, Sun Q, Liu C, Chen T, Li S, Wang W. Clinical features of severe wasp sting patients with dominantly toxic reaction: analysis of 1091 cases. PLoS One. 2013 Dec 31;8(12):e83164. PMID: 24391743; PMCID: PMC3877022. https://doi.org/10.1371/journal.pone.0083164