Retort to the article “Death due to Live Bee Acupuncture Apitherapy”

    On February 2018, it was published in Spain an article about a woman who would have died (date of the event not specified) after one bee sting, accusing apitherapy and concluding it’s “unsafe and unadvisable”. The article title is “Death due to Live Bee Acupuncture Apitherapy”, http://www.jiaci.org/revistas/vol28issue1_6-2.pdf by Vazquez-Revuelta P, Madrigal-Burgaleta R, from Allergy Division, Ramon y Cajal University Hospital, Madrid, Spain. In its content there are a number of unclear things and incomplete data, therefore a number of questions rise up.
    First, the article is less than one page. I wonder: is it enough space to solidly argue such severe conclusion, no matter the targeted domain, that it is “unsafe and unadvisable” ? Mostly observing that it was fast taken over in various countries, by very numerous and largely spread publications (search on Google).
    For those who don’t know the article, it’s advisable to read it before this one.
    To be clear about the symptoms that define anaphylactic shock, among a number there are two obligatory: stridor of larynx and hypotension. If these two signs are not present, it’s not anaphylactic shock. The development of symptoms is like this: first generalised rash, oedema and itch on the skin; then dyspnoea due to lowering the hole of larynx; then stridor of larynx, dizziness due to the low blood pressure,  and at the end loss of conciousness. Loss of consciousness doesn’t appear sudden after the contact with the allergen. Wheezing may appear or not, later than stridor of larynx. When stridor is present, if few minutes pass without treatment, the cyanosis (blue-violet colour) of the skin appears, due the lack of oxygen. Cyanosis appears first on lips, face, extremities of limbs and extends to entire body, if the lack of oxygen persists. No cyanosis after minutes, no anaphylactic shock.
    To understand, stridor of larynx mean a strong sound like a whistle, heard both on inspiration and expiration, coming from the throat, which is unmistakable with anything. It appears because of the oedema in the larynx that cause the closing of it, situation when the pass of the air produces the sound like whistle.
    Going to the article, it is written that immediately after one bee sting the patient developed “wheezing, dyspnoea, and sudden loss of consciousness”. It is not mentioned any skin reaction at the debut, neither the stridor of larynx, both obligatory for a certainly diagnose. Loss of consciousness doesn’t appear suddenly in anaphylactic shock. Cyanosis generalised on the skin has to be found, if they arrived at 30 minutes after the event, and that enters in the basic description of the patient in such emergency situation, because it shows a severe generalised lack of oxygen.
    To make the difference from larynx stridor, wheezing is a thinner and weaker sound like whistle, heard only on expiration, coming from the chest. It is produced by the constriction of the bronchi, that appears latter than oedema of larynx. Also unmistakable with anything.
    But what if the patient jumped some meals in that day, not sleep enough during the night (or nights) before, but worked during that day, and as a consequence in the apitherapy office she had hypoglycemia, when the loss of conscience may appear faster ? Or what if she developed a panic attack ?
    What if she made one of those vaccines considered as obligatory nowadays few weeks before, and developed one late allergy reaction (serum sickness) that may lead after some weeks to organs impairment and even anaphylactic shock ?
    The authors didn’t mention anything about the life style factors of the patient (processed food, synthetic beverages, working hard, sleeping few and late at night, exposure to electromagnetism,…), neither about possible anterior common medical treatments (vaccines, antibiotics) that could determine sometimes severe manifestations, including allergies ? Also nothing about investigating a possible exposure to toxins.
    In the hospital diagnose of anaphylactic shock enters obligatory the tryptase blood analysis. It is considered the one that confirms the anaphylactic shock. The blood level of tryptase reach the maximum level after the debut of anaphylactic shock in 40-60 minutes and remains high for 4-6 hours. The optimal interval to make the analysis is between 30 minutes and 3 hours from the debut of the problem. And for a patient suspected by anaphylactic shock tryptase analysis is among the basic ones in an emergency department, where she was admitted during this time. But it wasn’t made. Why ?
    Another element that usually sustains the ambulance diagnose of anaphylactic shock is the cyanosis of the skin related to the level of oxygen in the blood that should be low. If it is cyanosis, the oxygen mask is immediately requested, but that didn’t entered in the emergency treatment. Why ? We may presume cyanosis wasn’t present. Then why they say it was anaphylactic shock ?
    Also, related to the ambulance intervention, they don’t describe the rate, rhythm and amplitude of respiration, they only give the blood pressure and heart rate. Why, because the respiration is an essential vital sign watched and treated in emergency, along with heart rate and blood pressure ?
    If it’s not present the cyanosis which is the visible sign of severe hypo-oxygenation, one of the first acts in emergency is to measure the oxygen level in blood. This is very simply using a device applied on the finger of the patient, that is present in any ambulance. And if the oxygen is found low in the blood, is again an emergency to apply fast the oxygen mask, which it’s not mentioned.
    Why they didn’t measure the oxygen in the blood ? Maybe because there were no signs to suggest a low level of oxygen, as respiratory dysfunction that is not mentioned.
    Instead, they speak about respiratory intubation, decided by the Glasgow Coma Scale score on 6. But Glasgow Coma Scale is not related to the respiration. It is a neurological one, based on three examinations: eye, verbal and motor. Not this scale dictates the need of intubation, but the rate, rhythm and amplitude of breathing. But these are not described.
    Moreover, in anaphylactic shock it’s impossible to introduce the tube into the throat because the larynx closing. It doesn’t enter. In this case to make possible the respiration, tracheostomy is the emergency act. This mean to cut the skin for making a hole in trachea under the larynx and introduce in there a tube. This allows the air to enter in the lungs avoiding the closed larynx.
    Another thing: in anaphylactic shock it is present the constriction of bronchi, but this turns to normal after the adrenalin, along with the blood pressure and heart rate. They say that that blood pressure and heart rate were stabilized during the transport to the hospital. Why not the respiration ? In this case, again the question: what for intubation ? Only if the coma had another reason than anaphylactic shock, and the respiration dysfunction was present. And again a previous question: why they don’t write the rate, rhythm and amplitude of breathing ?
    The respiration may be affected also by a cerebral stroke localized in the brain-stem, when it is associated with heart arrhythmia that remains long time, creating troubles not only in emergency moment, but also during the hospitalization. But in this case the heart rate was stabilized during the transport to the hospital. Interesting is that the watershed stroke showed by CT has another location, in the hemispheres of the brain and produces different types of paralysis, not respiratory problems.
    Moreover, after arriving to the hospital, why it took 3 days to contact the allergy department for a patient considered in anaphylactic shock ? In such case, an allergy specialist should be called immediately, even announcing during the transport to the hospital.
    Why the ambulance doctors administered double dose of adrenalin ? It is not explained. Adrenalin acts by constriction of blood vessels on periphery (skin, abdominal organs) in order to direct the blood to the vital organs meaning brain, heart and lungs. If it doesn’t look like anaphylactic shock but they only thought it is because of the bee sting, then adrenalin wasn’t necessary. In this situation, a double dose of adrenaline could determine a strong constriction of the blood vessels in the abdominal organs meaning ischemia that may lead finally to their impairment.
    And what if the patient had hypoglycemia not anaphylactic shock and instead of glucose the ambulance administered adrenalin ? I
    And if the patient was in coma, why they administered intravenously saline solution, but not glucose solution, to sustain the brain ?
    After that, at the admission in the hospital, the computer tomography (CT) of the head was compatible with watershed stroke. Compatible means it was recently started, not completely installed. But they don’t confirm the watershed stroke  by another CT (or MRI) made after few days, as it is usually.
    Anyway, watershed stroke is cerebral infarction due to ischemia, that may be produced by two causes: prolonged hypotension or thrombosis. The last one mostly appears to persons with chronic carotid artery plaques, matter that can have no symptoms for long time, meaning to remain unknown and to manifest severely at once. To make the difference between brain ischemia by hypo-tension or by thrombosis, and to treat it adequately it is necessary to investigate the blood vessels state by arteriography and Doppler ultrasound. Again not mentioned.
    Brain injury requests the collaboration with a neurologist, also not mentioned. The neurological sufferance looks like incomplete described and treated during the hospitalization.
    As an example, hypoglycemia may appear when someone jumps meals, not sleep well and enough, but work hard or practice physical exercises. When in hypoglycemia the person can develop stupor, coma and abnormal breathing. Such hypoglycemia may lead to brain injury, if not treated in few minutes. But again the ambulance didn’t measure the blood glucose, even if it’s very simple using a glucometer that is a simple small device for emergency. By administering adrenalin, the glycemia may increase a bit, so as in the basic analysis of blood made in the hospital to look like normal.
    The impairment of many organs that they accuse, may have few systemic causes: toxic reaction or ischemia due to persistent hypotension or late allergy reaction. Not by anaphylactic shock directly.
    In a “persistent hypotension” appear in the blood analysis signs of severe hypoperfusion: metabolic acidosis, hyperlactacidemia, abnormal liver tests, coagulopathy. But they affirm the blood analysis at admission were normal. How is that possible ?  Or they didn’t analyze these important parameters ?
    In the case of late allergy reaction, the disease is named serum sickness, and it is diagnosed by the presence in the blood of fractions of serum complement and circulating immune complexes. Again these obligatory analysis don’t seam to be performed. Also they don’t mention imagistic investigations (MRI, computer tomography) to highlight the failure of organs, neither blood parameters specific for failure, at least for kidneys, when creatinine has high level. Anyway in the case of kidney failure the dialysis is necessary, another one not mentioned.
    Two of the causes of serum sickness are antibiotics and vaccines.
    In serum sickness symptoms appear usually after two weeks, rarely after minimum 4 days. The first symptoms include rash, itch, joint pains, enlarged lymph ganglions, but in 50% of cases these may not appear, therefore you don’t know you have it, before some severe manifestations may appear. What if she took some antibiotics (e.g. cephalosporins, penicillin, cefaclor, sulfonamide) or a vaccine about two weeks before ? In serum sickness, those complexes circulating in the blood determine inflammation and swelling of blood vessels that lowers the blood flow. Serum sickness may lead to kidney failure and anaphylactic shock. What if she was in a non-symptomatic situation at the moment of the apitherapy session, added a hypoglycemia, and right at that moment the severe manifestations of serum sickness appeared ? By the combination of these two possible factors, the hypoperfusion of blood and sufferance of organs is assured.
    If we don’t have elements of investigation to highlight hypoperfusion or serum sickness as cause of organs impairment, it remains the toxic one. For a patient in such severe condition, it is usual to search toxins in blood analysis. But they don’t write anything about that.
    The failure of organs is not documented neither its cause, but expressed only as an extension of the idea that the debut would have been anaphylactic shock.
    The entire description of this case looks superficial and incomplete. Moreover, numerous elements do not match each other. It is unacceptable for a scientific article.
    Their diagnose of anaphylactic shock on bee venom started from the bee sting, but was based only on incomplete symptoms and on IgE level of Apis mellifera. But we know that many patients under bee venom treatment have increased levels of IgE on bee venom, without any allergic reaction. If they have a normal life, they don’t develop allergies. Because allergic reactions are determined not only by the presence of IgE, but more by adding many disturbing life style factors (processed food, synthetic beverages, working hard, sleeping few and late at night which it’s usual in Spain, exposure to electromagnetism, antibiotics, vaccines,…).
    Now let’s count again:
    • no rash, no itch, no edema on the skin, no stridor of larynx at the debut
    • no cyanosis on the skin after 30 minutes from the debut
    • intubation in anaphylactic shock ?  Which it is impossible…
    • but no tracheostomy needed…
    • no oxygen level in the blood determined
    • no rate, rhythm and amplitude of respiration to attract attention in
                                  emergency in order to be described as severe
    • no tryptase determination in the hospital
    • no signs of persistent hypotension in the blood, in the hospital
    How they sustain the diagnose of anaphylactic shock ?
    • contact with the bee
    • wheezing, that doesn’t appear fast in anaphylactic shock
    • sudden loss of consciousness that doesn’t appear fast in  anaphylactic shock
    • IgE level in blood, which frequently are present without any allergic reaction
    Too few yes, which are weak and inconsistent for a correct diagnose of anaphylactic shock, that looks more subjective and forced than medical correctly.
    And too many NO which are obviously, medically speaking, against the diagnose of anaphylactic shock. I would rather say it wasn’t anaphylactic shock.
    Then what was that ? Considering the poverty of investigations, it’s impossible to understand what was the sufferance and its cause. We can’t  even be sure it was multi-organs impairment, because they don’t sustain it by anything, but only affirm it. Anyway, thinking it could be, we can only presume it could be toxic sufferance or serum sickness. Or who knows what ?
    Another thing: when someone dies in the hospital, it is obligatory by law the necropsy. Out of this result the report of the legal medicine on the cause of death, including the eye visible elements on body and inside of it and the microscopic description. Where are these. How to know the real cause of death ?
    But what if on that ambulance was a beginner physician, non experienced who didn’t diagnose and manage correctly the case ? And then in the hospital the physicians assumed his idea of anaphylactic shock and didn’t pay attention to other possible causes of the entire sufferance ?
    Even if it would be real, it's one case. During this time, apitherapy helps so many people that conventional medicine can not, and without important not-wanted effects. But how many people die exactly in the hospitals by allergic and toxic reactions on medicinal drugs, and no one declares conventional medicine as “unsafe and unadvisable” ? How many of the doctors working in their own offices are trained to treat such emergency situations at the level recommended by the authors for apitherapists ? Because all doctors work with substances that may provoke allergies. Do they make blood analysis and allergy tests before each antibiotic or vaccine injection ?
    Now looking at the structure of the article. For a medical scientific case report, there are number of obligatory elements accompanied by arguments to be included. I mention shortly:
    • medical history
    • detailed description of initial physical condition
    • initial medical investigations to sustain the diagnose; in this case anaphylactic shock
    • if the diagnose was added during the observation, again physical description, blood analysis, imagistic investigations to sustain; in this case watershet stroke, multi-organs impairment
    • evolution of symptoms
    • evolution of parameters investigated
    • if the case ended by death, compulsory the necropsy report to proof the cause of death
    • if adding references, they should be related to each point of the diagnose.
    The case report of this woman, if it would be presented by a student to his University Professor during an exam, he wouldn’t pass it. All the more for a specialized physician, it is embarrassing to sign such article.
    Related to the conventional medical system, I mention that, according to a recent warning of UN, on worldwide the number of deaths caused by the consume of medication equalizes the number of deaths caused by drugs.
    And that a large statistic made in USA reveals that the third cause of death is iatrogenic (meaning medical mistakes) after heart diseases and cancer. About quarter million people die annually by various iatrogenic causes. But these things do not enter in the official statistics. That explosive statistic was performed by Dr. Barbara Starfield, University Distinguished Service Professor at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine. The article was published in 2000  https://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-primary-care-policy-center/Publications_PDFs/A154.pdf with the title “Is US Health Really the Best in the World?”, in the journal of American Medical Association. Mass media showed a small and short interest for this alarming report, and the Government none. Dr. Starfield died suddenly in 2011, apparently due to a coronary event while swimming at her home. She had an intense activity around the world to share ideas, nurture young professionals, and push leaders to do better.
    To finalise, it looks like the aim of this too short article but enough to impact the non-advised public by the conviction with which the allegations are made, was to blame apitherapy, serving only the negative propaganda of Big Pharma, that considers any natural therapy as competitor. Because for the medical public and scientifically speaking, this article inconsistently argued is unconvincing and on low level. It can not intimidate us, the practitioners of apitherapy.
    So, dear apitherapists all over the world, continue with confidence to do what you believe in.

Dr. Cristina Aosan
MD - Specialist in General Medicine, Api-phyto-aroma-therapy licenced
Apimondia Apitherapy Commission, member
Licenced medical trainer in api-phyto-aroma-therapy

May 07, 2018

(posted May 13, 2018)

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