Neurological sequelae of massive bee envenomation: a rare case report of watershed cerebral infarction and hemorrhage

Introduction and significance: Bee stings are common but can cause severe systemic reactions, including anaphylaxis, cardiovascular instability, and, rarely, neurological complications such as watershed cerebral infarctions, as well as death. Stroke following bee envenomation is uncommon and may result from multiple pathological mechanisms. Case presentation: A 65-year-old male presented to the emergency department 30 minutes after sustaining more than 60 bee stings. He exhibited hypotension (BP 90/50 mmHg), hypoxia (SpO₂ 88%), generalized swelling, and respiratory distress. Initial management included intramuscular epinephrine, corticosteroids, antihistamines, nebulized bronchodilators, intravenous fluids, and tetanus prophylaxis. After stabilization, he developed acute left upper-limb weakness (power 2/5). Neuroimaging revealed multifocal acute infarcts in the ACA–MCA and MCA–PCA watershed regions, with hemorrhagic transformation. He was initially started on dual antiplatelet therapy and low-molecular-weight heparin, with the antithrombotic regimen later de-escalated to aspirin alone due to hemorrhagic conversion. Early physiotherapy and rehabilitation were initiated, resulting in gradual recovery, with near-complete restoration of left upper-limb function at six months. Discussion: Stroke after bee envenomation can arise from multiple mechanisms, including severe hypotension causing watershed infarcts, venom-induced vasospasm, inflammatory and pro-coagulant effects promoting thrombosis, and transient arrhythmias leading to cardioembolic events. Hemorrhagic transformation, as seen in this patient, adds complexity to antithrombotic management. Early recognition, hemodynamic stabilization, neurological monitoring, and timely rehabilitation are essential to optimize outcomes and prevent long-term deficits. Conclusion: Massive bee stings can precipitate life-threatening allergic reactions and rare cerebrovascular events. Clinicians should maintain vigilance for neurological complications, ensure early intervention, and implement structured rehabilitation to improve functional recovery.