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Original Question
Farnsworth P. Worthington, IV, a 71-year-old beekeeper, was stung by a honeybee 24 hours ago while working in his apiary. Within two to three minutes following the sting, he noticed a slightly red, raised area on his arm. Mr. Worthington states he has experienced numerous bee stings over his 39-year career as a beekeeper, typically resulting in mild localized reactions. He experienced no shortness of breath, wheezing, rapid heart rate, or other symptoms such as swelling of the lips, lightheadedness, nausea, or swelling. Today, he presents to the clinic with low-grade fever (99.7ºF [37.6ºC]). Since yesterday’s sting, a 4 cm diameter area of redness, tenderness, and induration with a central 1.1 cm area of necrosis and ulceration has developed. He has never experienced this type of reaction to a bee sting. Past Medical History: Chronic Conditions: None reported Immunization History: Up-to-date on influenza, tetanus, diphtheria, and pertussis Medications: Occasional naproxen for joint discomfort and antihistamines for mild allergies. Family History: No family history of autoimmune diseases or severe allergic reactions. Review of Systems: General: Well-developed, well-nourished, no acute distress; no fatigue, or malaise. Skin: No other rashes or lesions reported. Respiratory: No dyspnea or wheezing. Cardiovascular: No chest pain or palpitations Physical Examination: Vital Signs: Blood Pressure: 130/85 mmHg Heart Rate: 76 bpm Respiratory Rate: 16 breaths/min Temperature: 99.7ºF (37.6ºC) Neuro: no deficits noted HEENT: Unremarkable Neck: Supple; no thyromegaly Lungs: Clear to auscultation and percussion Heart: normal sinus rhythm; functional grade II systolic murmur Abdomen: soft; bowel sounds active in all quadrants Extremities: on the left arm 5 cm below the elbow, a 4 cm diameter red, tender, swollen, indurated and inflamed lesion was noted with a 1.1 cm area of central necrosis with ulceration. Lymphatics: There is no lymphadenopathy. Extremities: The other extremities are normal in appearance with normal range and motion. Laboratory results: CBC: Red blood cells (RBC): 4.9 million/mm3 (nl 4.35-5.65 million/mm3 men) Hematocrit (HCT) 42% (nl 40-55% men) Hemoglobin (Hgb): 14.9 g/dL (nl 13.0-16.0 g/dL) White blood cells (WBC): 11,300 million/mm3 (nl 5,000-10,000/mm3) Platelet count: 154,000 (nl 150,000-400,000/ mm3) Serum complement: C3: 190 mg/dL (nl80-178 mg/dL); C4: 55mg/dL (nl 12-42 mg/dL In your written submission, please provide information that answers the following: Based on the information provided, what is your diagnosis? (The scholarly title of your paper should inform the reader what the paper is about. Titles should not be “cute”. See information in instructions. Given the patient’s history of frequent bee stings, explain how type 3 hypersensitivity could explain the development of the current lesion as described? How does this response differ from a life-threatening hypersensitivity reaction to a bee sting? Analyze the significance of the elevated serum complement levels (C3 and C4) in the context of this patient’s presentation.
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