Bee and wasp stings in Deniyaya; a series of 322 cases 德尼亚亚的蜜蜂和黄蜂蜇伤；322 例系列病例
E W R A Witharana ^(1){ }^{1}, S K J Wijesinghe ^(1){ }^{1}, K S M Pradeepa ^(1){ }^{1}, W A I P Karunaratne ^(2){ }^{2}, S Jayasinghe ^(3){ }^{3} E W R A Witharana ^(1){ }^{1} 、S K J Wijesinghe ^(1){ }^{1} 、K S M Pradeepa ^(1){ }^{1} 、W A I P Karunaratne ^(2){ }^{2} 、S Jayasinghe ^(3){ }^{3}
Objectives To describe wasp and bee species that sting humans, analyse risk factors and clinical features. Methods A prospective observational study was conducted on patients presenting to Base Hospital Deniyaya with suspected bee and wasp stings from 2011 to 2013. Data were gathered using a questionnaire and specimens of offending insects collected for identification. When the insect specimen was unavailable, identification was made by the victim selecting (without prompting) from several dead specimens presented by the first author. 目的 描述蜇伤人类的黄蜂和蜜蜂种类，分析风险因素和临床特征。方法 对 2011 年至 2013 年期间到德尼亚基地医院就诊的疑似被蜜蜂和黄蜂蛰伤的患者进行前瞻性观察研究。研究采用问卷调查的方式收集数据，并采集昆虫标本进行鉴定。如果没有昆虫标本，则由受害者从第一作者提供的几种死亡昆虫标本中选择（无需提示）进行鉴定。
Results There were 322 patients (mean age: 42.5 years, SD: 15.1, 173 [53.7%] males). Insects were brought by 55 (17%) and 267 (83%) were identified using specimens. All occurred during day-time, 142 (44.1%) during August and September, and 200 victims (62%) were tea plantation workers. Majority ( 78.9%78.9 \% ) reported a localized painful self-limiting swelling without systemic features and 15 (4.6%) developed anaphylactic shock. None died. Five specimens were available from those in anaphylactic shock (four Apis dorsata, one Ropalidia marginata). Vespa tropica stinging caused a characteristic skin lesion. Of the 55 specimens, 46 ( 83.6%83.6 \% ) were Apis dorsata (Giant honey-bee, “Bambara”), 8 (14.5%) Vespa tropica (Greater banded hornet, “Debara”) and one Ropalidia marginata (Paper wasp, “Kaladuruwa”). 结果 共有 322 名患者（平均年龄：42.5 岁，标准差：15.1，男性 173 人 [53.7%]）。55人（17%）携带了昆虫，267人（83%）通过标本进行了鉴定。所有昆虫都发生在白天，142只（44.1%）发生在8月和9月，200名受害者（62%）是茶园工人。大多数人（ 78.9%78.9 \% ）报告了局部疼痛的自限性肿胀，没有全身特征，15人（4.6%）出现过敏性休克。没有人死亡。过敏性休克患者提供了五份标本（四份背蜂，一份边蜂）。Vespa tropica刺痛会引起特征性皮肤损伤。在 55 个标本中，46 个（ 83.6%83.6 \% ）是大蜜蜂（Apis dorsata，"Bambara"），8 个（14.5%）是大带蜂（Vespa tropica，"Debara"），1 个是纸蜂（Ropalidia marginata，"Kaladuruwa"）。
Conclusions Only three hymenoptera species stings were reported. Risk factors included day-time outdoor activities, occupation (tea plantation workers) and period of year. The latter may be due to pollen season when the insects are found in abundance. Only 4.6%4.6 \% of the patients developed anaphylactic shock. Vespa tropica stings led to a unique skin lesion. 结论 据报告，只有三种膜翅目昆虫被蜇伤。风险因素包括日间户外活动、职业（茶园工人）和年份。后者可能是由于花粉季节昆虫大量繁殖所致。只有 4.6%4.6 \% 名患者出现过敏性休克。Vespa tropica蜇伤会导致独特的皮肤损伤。
Ceylon Medical Journal 2015; 60: 5-9 锡兰医学杂志 2015; 60: 5-9
Introduction 导言
Worldwide fatal stings from insects probably result in an appreciable number of deaths. United States report 40 deaths due to insect stings and Australia, 2-3 全世界被昆虫蛰伤致死的人数可能相当可观。美国报告有 40 人死于昆虫蜇伤，澳大利亚报告有 2-3 人死于昆虫蜇伤。
deaths annually [1, 2]. Globally Emergency Department visits due to allergy and systemic envenomation after Hymenoptera sting are not uncommon [3]. 每年的死亡人数[1, 2]。在全球范围内，因被膜翅目昆虫蛰伤后过敏和全身中毒而到急诊室就诊的情况并不少见[3]。
Hymenopterans are insects broadly categorised into three families; Apidae (honeybees, bumblebees), Vespidae (hornets, wasps, and yellow jackets) and Formicidae (fire ants) [4]. In Sri Lanka, there are three reported species of wasps belonging to the genus Vespa namely V. affinis (Linnaeus), V. tropica (Linnaeus) and V. mandarinia (Smith) [5]. Old world paper wasp Ropalidia marginata is found in the Indian peninsula [6]. The domesticated Asian honeybee, Apis cerana (“Meemessa”), the feral giant honeybee, Apis dorsata (“Bambara”), the feral dwarf honeybee Apis florae (“Daduwel mee”) and the stingless bee, Trigonairidipennis (“Kaneyya messa”) are common honeybees found in rural and urban areas in Sri Lanka [7]. 膜翅目昆虫大致可分为三科：蛛科（蜜蜂、大黄蜂）、黄蜂科（大黄蜂、黄蜂和黄蜂）和蚁科（火蚁）[4]。在斯里兰卡，据报道有三种黄蜂属于 Vespa 属，即 V. affinis（林奈）、V. tropica（林奈）和 V. mandarinia（史密斯）[5]。印度半岛发现了旧世界纸蜂 Ropalidia marginata [6]。驯化的亚洲蜜蜂Apis cerana（"Meemessa"）、野生大蜜蜂Apis dorsata（"Bambara"）、野生矮蜜蜂Apis florae（"Daduwel mee"）和无刺蜂Trigonairidipennis（"Kaneyya messa"）是斯里兰卡城乡地区常见的蜜蜂[7]。
Effects of Hymenoptera sting can range from irritation to severe form of anaphylactic shock [1]. Multi organ failure, rhabdomyolysis, electrocardiographic changes, acute kidney injury and myocardial infarction are well known complications of mass envenomation due to hymenoptera sting [8-11]. There are reports of acute kidney injury, myocardial infarction, severe anaphylaxis and bowel gangrene after giant Asian honeybee or wasp sting in Sri Lanka [8,12-14]. 膜翅目昆虫蛰伤的影响范围从刺激到严重的过敏性休克[1]。多器官衰竭、横纹肌溶解、心电图改变、急性肾损伤和心肌梗塞是膜翅目昆虫蛰伤引起的众所周知的并发症 [8-11]。有报告称，在斯里兰卡，亚洲大蜜蜂或黄蜂蛰人后出现急性肾损伤、心肌梗塞、严重过敏性休克和肠坏疽[8,12-14]。
Epidemiological and clinical aspects of Hymenoptera stings are not well known in Sri Lanka. Many health care workers in rural areas lack in-depth knowledge about different species of Hymenopterans and clinical features resulting from stings. 在斯里兰卡，人们对膜翅目昆虫蛰伤的流行病学和临床方面并不十分了解。农村地区的许多医护人员对不同种类的膜翅目昆虫和蛰伤导致的临床特征缺乏深入了解。
Sri Lanka has extensive biodiversity with natural green vegetation ranging from low land rain forests to dry zone forests. Deniyaya is a rural area located close to the world heritage Sinharaja tropical rain forest. It is situated at high altitude and has many tea plantations [15]. Therefore, significant numbers of patients with insect attacks are admitted to the Deniyaya hospital for emergency treatment. 斯里兰卡拥有广泛的生物多样性，天然绿色植被从低地雨林到旱地森林一应俱全。德尼亚亚是一个农村地区，毗邻世界遗产辛哈拉加热带雨林。该地区海拔较高，有许多茶园[15]。因此，大量昆虫袭击患者被送往德尼亚亚医院接受紧急治疗。
Female hymenopterans have a stinging apparatus (stinger) which is a modified ovipositor located at the tip 雌性膜翅目昆虫有一种刺器（毒刺），它是一种改良的产卵器，位于顶端
of their abdomen and is associated with a venom gland [4]. The stinging apparatus is used as defence if the insect is disturbed. The stinger is detached from the body after a single sting by the honeybee and it dies thereafter. But a single wasp is capable of stinging multiple times as the stinger is not separated from the body after sting. This finding is useful to differentiate honeybee from wasp as wasps do not leave the stinger on the victim’s skin [14]. Venom glands of hymenopterans produce a variety of toxic substances including active amines (serotonin, histamine, tyramine, catecholamines), wasp kinins (similar in composition to bradykinins) and histaminereleasing peptides [9]. 蛰器位于昆虫腹部，与毒腺相连 [4]。如果昆虫受到惊扰，就会利用刺器进行防御。蜜蜂叮咬一次后，蜂刺就会与身体分离，随后蜜蜂就会死亡。但一只黄蜂能够蜇人多次，因为蜇人后毒刺不会与身体分离。这一发现有助于区分蜜蜂和黄蜂，因为黄蜂不会将毒刺留在受害者的皮肤上 [14]。膜翅目昆虫的毒腺会产生多种有毒物质，包括活性胺（5-羟色胺、组胺、酪胺、儿茶酚胺）、黄蜂激肽（成分类似于缓激肽）和组胺释放肽 [9]。
The aim of this study was to identify hymenopterans up to species level and characterise common risk factors and clinical features following different hymenoptera sting in Deniyaya, a rural area in Sri Lanka. 本研究的目的是在斯里兰卡农村地区德尼亚亚（Deniyaya）对膜翅目昆虫进行物种鉴定，并描述不同膜翅目昆虫蛰伤后的常见风险因素和临床特征。
Methods 方法
A prospective observational study was conducted at Deniyaya Base Hospital, Sri Lanka. Medical officers, collected data from patients admitted with stings of either bees or wasps during the two year period from September 2011 to August 2013. Only patients who confidently identified the insect during the incident as honeybees or wasp were included in the study and patients stung by insects other than bees and wasps were excluded. Specimens of the offending insect were collected for identification. In instances where the insect was not available, patient was asked to identify the insect from a series of dead specimens of stinging hymenopterans presented by the first author. All patients completed a questionnaire that gathered information on sociodemographic aspects, context and time of sting, features of offending insect, symptoms and treatment. Written informed consent was obtained from every patient. 斯里兰卡丹尼亚基地医院开展了一项前瞻性观察研究。医务人员收集了 2011 年 9 月至 2013 年 8 月两年期间因蜜蜂或黄蜂蛰伤入院的患者数据。只有在事发时能确定昆虫为蜜蜂或黄蜂的患者才被纳入研究范围，而被蜜蜂和黄蜂以外的昆虫蛰伤的患者则被排除在外。研究人员收集了昆虫标本进行鉴定。如果没有昆虫标本，则要求患者从第一作者提供的一系列刺膜翅目昆虫尸体标本中辨认昆虫。所有患者都填写了一份调查问卷，其中收集了社会人口学方面的信息、蛰伤的背景和时间、侵害昆虫的特征、症状和治疗方法。每位患者都获得了书面知情同意。
Detailed clinical history was obtained and all patients were examined to gather information regarding incident, identification of insect, allergic manifestations, vital signs, anaphylaxis and signs and symptoms of organ dysfunction. All patients were observed in the ward and blood pressure, pulse, respiratory rate and urine output were monitored. The investigators looked for presence of a stinger on the skin. If stingers were present they were immediately removed and the numbers were counted. Information was obtained whether the stinger was present on the skin because sometimes the stinger was removed before arrival at the hospital. The presence of a stinger is helped to differentiate honeybees from wasps. Reduced blood pressure (systolic blood pressure of less than 90 mm Hg or > 30%>30 \% decrease from that person’s baseline after exposure to known allergen) was considered as anaphylaxis in our patients [16]. Data entry and statistical analysis were done using Microsoft EXCEL. 对所有患者进行了详细的临床病史询问和检查，以收集有关事件、昆虫识别、过敏表现、生命体征、过敏性休克以及器官功能障碍的症状和体征的信息。在病房中对所有患者进行观察，监测血压、脉搏、呼吸频率和尿量。调查人员检查皮肤上是否有毒刺。如果发现毒刺，则立即将其拔除并统计数量。之所以要获得皮肤上是否有毒刺的信息，是因为有时毒刺会在抵达医院前被拔除。蜂刺的存在有助于区分蜜蜂和黄蜂。血压下降（收缩压低于90毫米汞柱或接触已知过敏原后血压比基线下降 > 30%>30 \% ）在我们的患者中被视为过敏性休克[16]。数据录入和统计分析使用 Microsoft EXCEL 完成。
Results 成果
A total of 11254 patients were admitted to medical wards during the study period and 322 of them were stung by wasps or honeybees. There were 173 (53.7%) males and 149 (46.3%) females. The mean age was 42.5 years, ( SD=15.1\mathrm{SD}=15.1 ). Two hundred and thirty six ( 73%73 \% ) of victims were aged 20-60 years. Ethnicity was 164 (50.9%) Sinhalese, 156 (48.4%) Tamils and 2 (0.7%) Muslims. 在研究期间，共有 11254 名病人入住内科病房，其中 322 人被黄蜂或蜜蜂蜇伤。其中男性173人（53.7%），女性149人（46.3%）。平均年龄为 42.5 岁（ SD=15.1\mathrm{SD}=15.1 ）。236名（ 73%73 \% ）受害者的年龄在20-60岁之间。种族为 164（50.9%）名僧伽罗人，156（48.4%）名泰米尔人和 2（0.7%）名穆斯林。
Thirty patients ( 9.3%9.3 \% ) were stung by wasps and 292 ( 90.7%90.7 \% ) were stung by honeybees. In the 30 patients who identified hymenopterans as wasps (29 Vespa and one Ropalidia marginata) stingers were not found on the victim’s skin. Also the victims of wasp sting could identify wasp as Vespa as they are bigger than bees and by the presence of yellow bands on the abdomen of the insect. One patient identified the offending insect as Ropalidia marginata and this was confirmed by identifying the specimen of insect. In the 292 patients who were victims of honeybee sting (feral giant Asian honeybee, Apis dorsata, the “Bambara”) stingers were embedded in the skin. All patients with stingers on the skin were stung by Apis dorsata (feral giant honeybee). This was easily identifiable as it is the largest (17-20 mm in length) and the most aggressive honey bee in the country. Apis cerana (“Mee messa”), the feral dwarf honeybee Apis florae (“Daduwel mee”) were excluded as they were smaller in size compared to feral giant honeybee (Apis dorsata). 30名患者（ 9.3%9.3 \% ）被黄蜂蜇伤，292名患者（ 90.7%90.7 \% ）被蜜蜂蜇伤。在 30 名将膜翅目昆虫辨认为黄蜂的患者（29 名 Vespa 和 1 名 Ropalidia marginata）的皮肤上没有发现蜂刺。此外，被黄蜂蜇伤的受害者也能辨认出黄蜂是蜂，因为它们比蜜蜂大，而且昆虫腹部有黄带。一名患者辨认出螫伤的昆虫是边缘蝇（Ropalidia marginata），并通过辨认昆虫标本得到证实。在 292 名被蜜蜂（亚洲野生大蜜蜂，Apis dorsata，"Bambara"）蜇伤的患者中，蜂刺嵌入了皮肤。所有皮肤上有蜂刺的患者都是被亚洲野生大蜜蜂（Apis dorsata）蜇伤的。这种蜜蜂很容易辨认，因为它是该国最大的蜜蜂（体长 17-20 毫米），也是最具攻击性的蜜蜂。与野外大蜜蜂（Apis dorsata）相比，野外侏儒蜜蜂Apis florae（"Daduwel mee"）体型较小，因此被排除在外。
Species level identification was made in 55 specimens brought by the patients. Of them 46 were Apis dorsata, eight were Vespa tropica and one was Ropalidia marginata, identification was done according to characteristic morphological features (Figure 1). Sinhala names for Apis dorsata, Vespa tropica, and Ropalidia marginata are “Bambara”, “Debara” and “Kaladuruwa” respectively. A worker giant Asian honeybee is approximately 17-20mm17-20 \mathrm{~mm} long and has a hair covered body [14]. The length of Vespa tropica female is 19-30mm19-30 \mathrm{~mm} with a large, stout body covered with strong, stiff hairs and the second gastraltergite (2nd dorsal shield of the abdomen) is yellow with a slight brown area basally [17]. 对患者带来的 55 份标本进行了物种鉴定。根据形态特征进行了鉴定（图 1）。蜜蜂的僧伽罗语名称分别为 "Bambara"、"Debara "和 "Kaladuruwa"。巨型亚洲蜜蜂的工蜂长约 17-20mm17-20 \mathrm{~mm} ，身体被毛覆盖[14]。Vespa tropica雌蜂体长 19-30mm19-30 \mathrm{~mm} ，身体粗壮，被坚硬的毛发覆盖，第二腹盾（腹部第二背盾）呈黄色，基部略带褐色[17]。
During the 2 year study period from 2011 to 2013 majority of cases were reported at the end of the year with a peak (44.1%) in August and September. The highest number of cases ( n=49\mathrm{n}=49 ) was reported in August 2013, whereas lowest number ( 3.7%3.7 \% ) of patients was reported from January to March each year. During this period the number did not exceed six per month (Figure 2). 在2011年至2013年的两年研究期间，大多数病例在年底报告，8月和9月为高峰（44.1%）。2013年8月报告的病例数最多（ n=49\mathrm{n}=49 ），而每年1月至3月报告的病例数最少（ 3.7%3.7 \% ）。在此期间，每月病例数不超过 6 例（图 2）。
Interestingly, all cases were reported between 6.00 am to 7.00 pm , indicating stinging occurred during day time. Peak incidence was ( n=62\mathrm{n}=62 ) from 11.00 am - 12.00 noon. 有趣的是，所有病例都发生在上午 6:00 至下午 7:00 之间，这表明蛰伤发生在白天。发病高峰（ n=62\mathrm{n}=62 ）为上午 11:00 至中午 12:00。
Two hundred ( 62%62 \% ) were stung by honeybees or wasps while working in the tea plantation. Eighty eight were stung while walking along roads or foot paths, four people while indoors and another two when trying to remove a wasp nest (Table 1). 有 200 人（ 62%62 \% ）在茶园工作时被蜜蜂或黄蜂蛰伤。有 88 人是在道路或人行道上行走时被蜇伤的，有 4 人是在室内被蜇伤的，另有 2 人是在试图清除马蜂窝时被蜇伤的（表 1）。
Seventeen had used permute when they were stung by hymenopterans. Thirty ( 9.3%9.3 \% ) patients had mass envenomation that could have lead to multi-organ failure (i.e. carried more than 100 stings per person), but none developed these complications. All patients with more than 100 stings were stung by bees. Majority with honeybee stings ( 66.1%66.1 \% ) had more than 10 stings per person whereas patients stung by wasps had less than 10 stings per person. 17人在被膜翅目昆虫蜇伤时使用过烫伤药。30（ 9.3%9.3 \% ）名患者被大量蛰伤，可能导致多器官衰竭（即每人被蛰超过100次），但没有人出现这些并发症。所有被蜇超过 100 次的患者都是被蜜蜂蜇伤的。大多数被蜜蜂蜇伤的患者（ 66.1%66.1 \% ）每人被蜇伤10次以上，而被黄蜂蜇伤的患者每人被蜇伤不到10次。
All patients developed pain over the stinging site and 79.2%79.2 \% had swelling over the site of the sting. Facial puffiness was reported in 37.3%37.3 \% and nausea or vomiting in 16.5%16.5 \%. Bronchospasms ( 2.5%2.5 \% ), change of voice ( 0.6%0.6 \% ), throat pain ( 0.9%0.9 \% ) and abdominal pain (2.1%)(2.1 \%) were reported in lesser number of patients. These symptoms were not reported in the patients stung by wasps (Table 2). 所有患者的蜇伤部位都出现疼痛， 79.2%79.2 \% 的蜇伤部位出现肿胀。据报告， 37.3%37.3 \% 面部浮肿， 16.5%16.5 \% 恶心或呕吐。较少患者出现支气管痉挛（ 2.5%2.5 \% ）、变声（ 0.6%0.6 \% ）、喉咙痛（ 0.9%0.9 \% ）和腹痛（ (2.1%)(2.1 \%) ）。被黄蜂蜇伤的患者没有出现这些症状（表 2）。
Table 2. Clinical features due to bee and wasp stings 表 2.蜜蜂和黄蜂蜇伤的临床特征
Clinical features 临床特征
蜂蜇 n(%)n(\%)
Bee sting
n(%)n(\%)
Bee sting
n(%)| Bee sting |
| :---: |
| $n(\%)$ |
黄蜂蜇伤 n(%)n(\%)
Wasp sting
n(%)n(\%)
Wasp sting
n(%)| Wasp sting |
| :---: |
| $n(\%)$ |
Majority (78.9%) had localized painful selflimiting swelling without systemic features. Fifteen (4.6%) developed anaphylactic shock after exposure to Hymenoptera venom but none of them died. Thirteen (4.5%) of those who developed anaphylaxis were stung by bees. 大多数患者（78.9%）有局部疼痛的自限性肿胀，没有全身特征。15人（4.6%）在接触膜翅目昆虫毒液后出现过敏性休克，但无一人死亡。过敏性休克患者中有 13 人（4.5%）是被蜜蜂蜇伤的。
Figure 3. (a) Characteristic skin lesion over the stinging site of Vespa tropica (b) Erythematous lesion over the stinging site of Apis dorsata. 图 3：（a）热带蝰刺痛部位的特征性皮损（b）背喙蜂刺痛部位的红斑皮损。
We observed a characteristic cutaneous lesion over the sting site of the wasp, Vespa tropica [18]. In bee stings (Apis dorsata), there was a stinger and some patients developed an erythematous lesion over the stinging site (Figure 3). 我们观察到黄蜂（Vespa tropica）蜇伤部位有特征性皮肤损伤[18]。被蜜蜂（Apis dorsata）蜇伤后，一些患者的蜇伤部位会出现红斑（图 3）。
Two patients were transferred to a tertiary care hospital where more facilities were available. One patient developed a red eye after a single bee sting over the sclera and another with more than 1000 stings all over the body. 两名患者被转到了一家设施更完善的三级医院。一名患者被蜜蜂蛰了一下巩膜就出现了红眼病，另一名患者全身被蛰了 1000 多下。
Discussion 讨论
Our study showed that 2.9%2.9 \% of medical ward admissions sought emergency treatment after wasp or bee stings at Base Hospital, Deniyaya. The reason may be that Deniyaya has tea plantations and forests with plenty of nesting sites for insects. Majority of victims of bee and wasp sting were aged 20-60 years which consists of the working population. 我们的研究表明， 2.9%2.9 \% 在德尼亚基地医院的病房中，有很多人在被黄蜂或蜜蜂蜇伤后寻求紧急治疗。原因可能是德尼亚有茶园和森林，有大量昆虫筑巢的地方。被蜜蜂和黄蜂蛰伤的受害者大多年龄在20-60岁之间，其中包括工作人口。
Majority of people were stung ( 62%62 \% ) when they were working in tea plantations. The area is abundant with tea plantations and according to 90 victims, both honeybees and wasps nest on tea bushes (28%). Many people encroaching in the territorial range are stung when bees and wasps are provoked. A significant number of patients ( 29%29 \% ) were stung while they were walking on the road. Most ( 98.2%98.2 \% ) were stung when victims were engaged in outdoor activities. All cases were reported during day time from 6.00 am to 7.00 pm indicating that bees and wasps of this area were active during day time. 大多数人是在茶园工作时被蜇伤的（ 62%62 \% ）。该地区有大量茶园，据 90 名受害者称，蜜蜂和黄蜂都在茶树丛中筑巢（占 28%）。当蜜蜂和黄蜂被激怒时，许多侵入其领地范围的人都会被蜇伤。相当多的患者（ 29%29 \% ）是在路上行走时被蛰的。大多数患者（ 98.2%98.2 \% ）是在户外活动时被蜇伤的。所有病例都发生在上午 6:00 至下午 7:00 的白天，这表明该地区的蜜蜂和黄蜂在白天非常活跃。
Giant Asian Honeybees make their nest in an open area and thousands of bees hang from the nest. Once bees are disturbed, thousands of colony members leave the nest and attack intruders within their territorial range. Unlike 巨型亚洲蜜蜂在空旷的地方筑巢，成千上万只蜜蜂悬挂在巢上。一旦蜜蜂受到惊扰，成千上万的蜂群成员就会离开巢穴，攻击其领地范围内的入侵者。不同于
honeybees, wasps (Vespa) build their nests enclosed, using paper like material and hence only few insects can be seen from outside. Therefore, mass envenomation may be common with stings by honeybees than wasps. 蜜蜂、黄蜂（Vespa）的巢都是封闭的，使用类似纸张的材料，因此从外面只能看到很少的昆虫。因此，与黄蜂相比，蜜蜂蜇人可能更常见。
The highest number of patients presented during the period August to September whereas the lowest number patients were reported in January to March. The reason for this seasonal variation is not known though it may be related to periods when pollination is high. Rain fall and other human activities too could contribute. 8 月至 9 月期间发病人数最多，而 1 月至 3 月期间发病人数最少。这种季节性变化的原因尚不清楚，但可能与授粉高峰期有关。降雨和其他人类活动也可能是原因之一。
Honeybees are attracted to specific colours and smells [19]. Only a few victims had used perfumes as most of villagers and farmers who rarely used perfumes. Some patients reported that nests of honeybees may be damaged and carnivorous birds (eagles or other birds) feed on pupa. 蜜蜂会被特定的颜色和气味所吸引 [19]。只有少数受害者使用过香水，因为大多数村民和农民很少使用香水。一些患者报告说，蜜蜂的巢穴可能会遭到破坏，食肉鸟类（老鹰或其他鸟类）会以蛹为食。
Clinical features varied from simple erythema to severe form of anaphylaxis. There is one previous study conducted in Anuradhapura District which describes Vespa affinis stings. According to this study 6.4%6.4 \% developed anaphylaxis and most of the victims were agricultural workers [3]. Even though several species of honey bees and wasps have been reported in Sri Lanka, in Deniyaya area, hymenoptera strings were reported only of Asian giant honey bee (Apis dorsata), grater banded hornet (Vespa tropica) and paper wasp (Ropalidia marginata). 临床特征从简单的红斑到严重的过敏性休克不等。之前在阿努拉德普勒地区进行的一项研究描述了 Vespa affinis 的蜇伤情况。根据这项研究， 6.4%6.4 \% 出现了过敏性休克，大多数受害者是农业工人 [3]。尽管斯里兰卡曾报道过多种蜜蜂和黄蜂，但在德尼亚亚地区，仅报道了亚洲大蜜蜂（Apis dorsata）、大带胡蜂（Vespa tropica）和纸蜂（Ropalidia marginata）等膜翅目昆虫。
In conclusion, as significant number of patients ( 3%3 \% of medical admissions) present with Hymenoptera stings and 4.6%4.6 \% developed anaphylaxis, the primary health care workers at hospitals located in high risk areas should have proper training and access to emergency medications. The characteristic lesion over stinging site of Vespa tropica described above may be used by physicians to identify the species when the specimen of the insect is not available. 总之，由于大量患者（ 3%3 \% 入院患者）被膜翅目昆虫蛰伤并 4.6%4.6 \% 出现过敏性休克，位于高风险地区的医院的初级卫生保健人员应接受适当的培训并获得急救药物。在没有昆虫标本的情况下，医生可以根据上述热带蝰蛰伤部位的特征性病变来确定昆虫的种类。
Acknowledgements 致谢
We thank Dr. Udaya Ranawaka, Department of Clinical Medicine, University of Kelaniya and Dr. Arosha Dissanayake, Department of Clinical Medicine, University of Ruhuna for their valuable advice and staff of Deniyaya Base Hospital for support in conducting this study. 我们感谢凯拉尼亚大学临床医学系 Udaya Ranawaka 博士和鲁胡纳大学临床医学系 Arosha Dissanayake 博士的宝贵建议，并感谢 Deniyaya 基地医院的员工为本研究提供的支持。
Declaration of Interest 利益申报
There are no conflicts of interest. 没有利益冲突。
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^(1){ }^{1} Base Hospital, Deniyaya, 2Department of Zoology, University of Peradeniya and ^(3){ }^{3} Department of Clinical Medicine, University of Colombo, Sri Lanka. ^(1){ }^{1} 基地医院，德尼亚亚；2动物学系，佩拉德尼亚大学； ^(3){ }^{3} 临床医学系，科伦坡大学，斯里兰卡。
Correspondence: EWRAW, e-mail: elapathawitharana@gmail.com. Received 16 September and revised version accepted 7 November 2014. Competing interests: none declared. 通讯：EWRAW, e-mail：elapathawitharana@gmail.com。2014年9月16日收到，11月7日接受修订版。竞争利益：未声明。
