CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 4, September/October 2023 AFRICA 257 He was transported to our ED via road ambulance the same night. On arrival, his vitals were: heart rate 89 beats per minute, blood pressure 171/110 mmHg, respiratory rate 18 breaths per minute and temperature 37.3°C. Laboratory investigations showed rising hsTnI and elevated NT-proBNP levels (Fig. 2). A transthoracic echocardiogram (TTE) showed left ventricular (LV) segmental dysfunction (inferior, posterior and lateral wall systolic dysfunction, estimated LV ejection fraction of 45%). A thoracic and abdominal computed tomography (CT) aortogram to rule out aortic dissection was unremarkable. Therefore, the provisional diagnosis at that time was allergic myocarditis due to bee sting toxin with a differential diagnosis of ACS. The patient was treated with a single antiplatelet agent (aspirin) for ACS, antihypertensives, an anti-inflammatory (methylprednisolone), and atorvastatin for plaque stabilisation. Serial ECG the next day (day five) suggested the development of interior ST-segment elevation myocardial infarction (increased T-wave inversion of II/III/aVF leads, ST elevation with pathological Q waves on lead III) (Fig. 1B, C). He was then admitted into the cardiology ward on day six, by which time cardiac symptoms had largely resolved despite peaking hsTnI and NT-proBNP levels (Fig. 2). Antihistamine (loratadine) was added and basal-bolus insulin was given for the likely undiagnosed type 2 diabetes (haemoglobin A1c was 10.0%). Elevation of complement C3 was also detected (Fig. 2). A serial ECG monitor showed gradual recovery of ST elevation in the next few days with persistent pathological Q- and T-wave inversion (Fig. 1D). Fig. 1. ECG of the patient after a bee sting. A: 34 hours after the sting, the patient developed cardiac-type chest pain and the ECG showed T-wave inversion in the inferior leads (II, III, aVF). B: three days after onset of chest pain, the ECG showed increased T-wave inversion in the inferior leads with the development of pathological Q wave and ST-segment elevation in lead III. C: four days after onset of chest pain, the ECG showed similar T-wave inversion but more significant ST-segment elevation in the inferior leads (II, III, aVF) and deeper Q waves in lead III. D: nine days after onset of chest pain (patient was already asymptomatic at this time), the ECG showed ongoing T-wave inversion in the inferior leads but recovery of ST-segment and stable Q waves in lead III. A C B D CK-MB and CRP levels hsTnl (ng/ml) Fig. 2. Serum levels of cardiac markers and C-reactive protein (CRP). Dynamic changes in levels of hsTnI (reference range: 0–0.06 ng/ml; right y-axis), creatine kinase-MB (CK-MB) (reference range: 2–25 U/l; left y-axis) and CRP (reference range: 0–8 mg/l; left y-axis) indicated the occurrence of cardiac damage after a bee sting. A repeat of the cardiac markers on the day of admission to the cardiology ward showed hsTnI was still peaking at that time despite resolution of the symptoms.
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