NEJM

man-suffers-rare-bee-sting-directly-to-the-eyeball—it-didn’t-go-well

Man suffers rare bee sting directly to the eyeball—it didn’t go well

Nightmare fuel —

He did recover. No disturbing images in the article, but a link for those who dare.

Bees fly to their hive.

Enlarge / Bees fly to their hive.

In what may be the biological equivalent to getting struck by lightning, a very unlucky man in the Philadelphia area took a very rare bee sting directly to the eyeball—and things went badly from there.

As one might expect, the 55-year-old went to the emergency department, where doctors tried to extract the injurious insect’s stinger from the man’s right eye. But it soon became apparent that they didn’t get it all.

Two days after the bee attack, the man went to the Wills Eye Hospital with worsening vision and pain in the pierced eye. At that point, the vision in his right eye had deteriorated to only being able to count fingers. The eye was swollen, inflamed, and bloodshot. Blood was visibly pooling at the bottom of his iris. And right at the border between the man’s cornea and the white of his eye, ophthalmologists spotted the problem: a teeny spear-like fragment of the bee’s stinger still stuck in place.

(Images of the eye and stinger fragment are here for those who aren’t squeamish. The white arrow in Panel A shows the location of the stinger fragment while the asterisk marks the pooled blood.)

Get thee to an ophthalmologist

In a report published recently in the New England Journal of Medicine, treating ophthalmology experts Talia Shoshany and Zeba Syed made a critical recommendation: If you happen to be among the ill-fated few who are stung in the eye by a bee, you should make sure to see an eye doctor specifically.

“I am not surprised that the ER missed a small fragment,” Shoshany told Ars over email. “They pulled out the majority of the stinger, but the small fragment was only able to be visualized at a slit lamp,” she said, referring to a microscope with a bright light used in eye exams. In this case, they visualized the stinger at 10X or 16X magnification with the additional help of a fluorescent dye. Moreover, after spotting it, the stinger fragment “needed to be pulled out with ophthalmic-specific micro-forceps.”

After finally getting the entirety of the wee dagger out, Shoshany and Syed prescribed a topical antibacterial and prednisolone eye drops (a steroid for inflammation). At a five-month follow-up, the patient had recovered and the vision in his right eye had improved to 20/25.

For those now in fear of eye stings, Soshany has some comforting words: “Ocular bee stings are very rare.” She noted this was the first one she had seen in her career. Although there are documented cases in the scientific literature, the incidence rate is unknown. The odds of getting struck by lightning, meanwhile, are 1 in 15,300, according to the National Weather Service.

But one troubling aspect of this case is that it’s unclear why the man was stung to begin with. According to Shoshany, the man worked on a property with a beehive, but he didn’t work with the insects himself. “He reports he was just walking by and several bees flew up to him; one stung him in the eye,” she said. It’s unclear what provoked them.

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Teen’s vocal cords act like coin slot in worst-case ingestion accident

What are the chances? —

Luckily his symptoms were relatively mild, but doctors noted ulceration of his airway.

Teen’s vocal cords act like coin slot in worst-case ingestion accident

Most of the time, when kids accidentally gulp down a non-edible object, it travels toward the stomach. In the best-case scenarios for these unfortunate events, it’s a small, benign object that safely sees itself out in a day or two. But in the worst-case scenarios, it can go down an entirely different path.

That was the case for a poor teen in California, who somehow swallowed a quarter. The quarter didn’t head down the esophagus and toward the stomach, but veered into the airway, sliding passed the vocal cords like they were a vending-machine coin slot.

 Radiographs of the chest (Panel A, postero- anterior view) and neck (Panel B, lateral view). Removal with optical forceps (Panel C and Video 1), and reinspection of ulceration (Panel D, asterisks)

Enlarge / Radiographs of the chest (Panel A, postero- anterior view) and neck (Panel B, lateral view). Removal with optical forceps (Panel C and Video 1), and reinspection of ulceration (Panel D, asterisks)

In a clinical report published recently in the New England Journal of Medicine, doctors who treated the 14-year-old boy reported how they found—and later retrieved—the quarter from its unusual and dangerous resting place. Once it passed the vocal cords and the glottis, the coin got lodged in the subglottis, a small region between the vocal cords and the trachea.

Luckily, when the boy arrived at the emergency department, his main symptoms were hoarseness and difficulty swallowing. He was surprisingly breathing comfortably and without drooling, they noted. But imaging quickly revealed the danger his airway was in when the vertical coin lit up his scans.

“Airway foreign bodies—especially those in the trachea and larynx—necessitate immediate removal to reduce the risk of respiratory compromise,” they wrote in the NEJM report.

The teen was given general anesthetic while doctors used long, optical forceps, guided by a camera, to pluck the coin from its snug spot. After grabbing the coin, they re-inspected the boy’s airway noting ulcerations on each side matching the coin’s ribbed edge.

After the coin’s retrieval, the boy’s symptoms improved and he was discharged home, the doctors reported.

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The puzzling case of a baby who wouldn’t stop crying—then began to slip away

A studio portrait of a crying baby.

Enlarge / A studio portrait of a crying baby.

It’s hard to imagine a more common stressor for new parents than the recurring riddle: Why is the baby crying? Did she just rub her eyes—tired? Is he licking his lips—hungry? The list of possible culprits and vague signs, made hazier by brutal sleep deprivation, can sometimes feel endless. But for one family in New England, the list seemed to be swiftly coming to an end as their baby continued to slip away from them.

According to a detailed case report published today in the New England Journal of Medicine, it all started when the parents of an otherwise healthy 8-week-old boy noticed that he started crying more and was more irritable. This was about a week before he would end up in the pediatric intensive care unit (PICU) of the Massachusetts General Hospital.

His grandmother, who primarily cared for him, noticed that he seemed to cry more vigorously when the right side of his abdomen was touched. The family took him to his pediatrician, who could find nothing wrong upon examination. Perhaps it was just gas, the pediatrician concluded—a common conclusion.

Rapid decline

But when the baby got home from the doctor’s office, he had another crying session that lasted hours, which only stopped when he fell asleep. When he woke, he cried for eight hours straight. He became weaker; he had trouble nursing. That night, he was inconsolable. He had frantic arm and leg movements and could not sleep. He could no longer nurse, and his mother expressed milk directly into his mouth. They called the pediatrician back, who directed them to take him to the emergency room

There, he continued to cry, weakly and inconsolably. Doctors ordered a series of tests—and most were normal. His blood tests looked good. He tested negative for common respiratory infections. His urinalysis looked fine, and he passed his kidney function test. X-rays of his chest and abdomen looked normal, ultrasound of his abdomen also found nothing. Doctors noted he had high blood pressure, a fast heart rate, and that he hadn’t pooped in two days. Throughout all of the testing, he didn’t “attain a calm awake state,” the doctors noted. They admitted him to the hospital.

Four hours after he first arrived at the emergency department, he began to show signs of lethargy. Meanwhile, magnetic resonance imaging of his head found nothing. A lumbar puncture showed possible signs of meningitis—high red-cell count and protein levels—and doctors began courses of antibiotics in case that was the cause.

Six hours after his arrival, he began losing the ability to breathe. His oxygen saturation had fallen from an initial 97 percent to an alarming 85 percent. He was put on oxygen and transferred to the PICU. There, doctors noted he was difficult to arise, his head bobbed, his eyelids drooped, and he struggled to take in air. His cry was weak, and he made gurgling and grunting noises. He barely moved his limbs and couldn’t lift them against gravity. His muscles went floppy. Doctors decided to intubate him and start mechanical ventilation.

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