Bee Sting–Induced Ischemic Stroke with Divergent Outcomes: A Case Report and Review of 39 Cases

Background. Bee sting–induced ischemic stroke is a rare but increasingly recognized complication of Hymenoptera envenomation, with fewer than 40 imaging-confirmed cases documented in the world literature. The pathophysiology involves concurrent mechanisms including cerebral vasospasm, immune-mediated thrombosis, disseminated intravascular coagulation, and direct neurotoxicity, and no standardized management protocol has been established. Case presentation. We report two Asian Indian male patients of South Asian ethnicity with honeybee sting–induced ischemic stroke and markedly divergent clinical trajectories. Case 1, a 70-year-old coal-mine worker, sustained approximately 200 stings and developed multifocal embolic infarcts across anterior and posterior circulations, complicated by acute kidney injury, recurrent tracheostomy occlusion requiring multiple bronchoscopy sessions, nosocomial carbapenem-resistant superinfection, and progressive multi-organ failure; he was discharged against medical advice in a comatose, ventilator-dependent state. Case 2, a 47-year-old previously healthy man, sustained over 100 stings and developed a delayed posterior circulation syndrome on Day 2, with diffusion-weighted imaging confirming embolic infarcts in the bilateral cerebellar hemispheres, vermis, right occipital lobe, right thalamus, and splenium of the corpus callosum; he recovered fully with anticoagulation and supportive care. Conclusions. A review of 39 cases demonstrates stroke onset ranging from minutes to 14 days after envenomation, involvement of all vascular territories, and outcomes spanning full neurological recovery to death. Mass envenomation burden, disseminated intravascular coagulation, and multi-organ dysfunction consistently portend the worst prognoses. Early neurological assessment, prompt MRI neuroimaging, and concurrent anti-allergic and stroke-specific management are essential in all patients sustaining multiple bee stings.