Early Plasma Exchange for Multiple Organ Failure Following Massive Wasp Stings: A Case Report

Most wasp stings cause only mild local symptoms; however, in rare cases, venom-induced multiple organ failure (MOF) leads to life-threatening systemic complications for which no standardized treatments exist. Wasp venom contains enzymes, amines, and peptides that cause rhabdomyolysis, acute kidney injury (AKI), hepatotoxicity, and disseminated intravascular coagulation (DIC). Extracorporeal blood purification therapies, including therapeutic plasma exchange (TPE), have been proposed as potential treatments, although their indications and efficacy remain unclear. In this report, we present a case of severe MOF following multiple hornet stings that was successfully treated with early TPE, with the aim of highlighting the role of early TPE in patient survival. A 78-year-old woman was stung by a swarm of hornets during a mountain hike and became immobilized. Emergency medical services found her in shock with impalpable radial pulses and transported her to our hospital. On arrival, her vitals were as follows: Glasgow Coma Scale (GCS) score, E3V4M6; heart rate, 82 beats/min; blood pressure, 84/51 mmHg; respiratory rate, 28 breaths/min; and oxygen saturation, 100% while receiving 10 L/min of oxygen via a reservoir mask. A total of 78 sting sites were identified, with 11 retained stingers on the scalp. Initial laboratory findings revealed hepatic injury (aspartate aminotransferase (AST), 2,236 U/L; alanine aminotransferase (ALT), 628 U/L; and lactate dehydrogenase (LDH), 1,143 U/L), renal dysfunction (blood urea nitrogen (BUN), 23.8 mg/dL and creatinine (Cr), 1.14 mg/dL), coagulopathy (prothrombin time-international normalized ratio, 1.64 and activated partial thromboplastin time >200 s), and gross hematuria. Diagnosed with anaphylactic shock, she was immediately treated with intramuscular adrenaline (0.3 mg), corticosteroids, and antihistamines. All retained stingers were promptly removed. Approximately four hours after admission, her hepatic and renal functions deteriorated further. A single session of TPE was performed eight hours after admission, during which approximately 2.4 L of plasma was replaced with 20 units of fresh frozen plasma. After TPE, hepatic and renal functions gradually improved. Oxygen demand transiently increased, requiring a non-rebreather mask at 9 L/min; however, intubation was avoided. On day 2, liver enzyme levels peaked (AST, 2,362 U/L; ALT, 742 U/L), renal function improved, and creatine kinase (CK) levels rose to 19,815 U/L. On day 4, CK levels peaked at 39,239 U/L and subsequently declined. The patient was transferred from the intensive care unit to a general hospital ward on day 5 and was discharged on day 22 following full recovery. In severe hornet envenomation with systemic complications, such as MOF and DIC, early intensive care with TPE may be beneficial. Further studies are required to clarify the optimal timing, modality, and indications for blood purification therapies in wasp venom toxicity.