Oxalate-induced nephropathy from ingestion of oxalic acid used miticide in beekeeping

Polarizable calcium oxalate microcrystals in a 16-year-old who ingested a small volume (<10 mL) of oxalic acid solution + grain alcohol (90% ethanol). The patient presented with a diffuse morbilliform rash, intermittent fevers, oral lesions and alterations in taste, and a 10-day history of intractable emesis, a BUN of 126 mg/dL and a SCr of 9.4 mg/dL (non-oliguric). The patient’s AKI gradually improved after IVF and oral intake, and the SCr decreased to 1.9 mg/dL on discharge; follow-up SCr in clinic ~1 month later was 0.9 mg/dL. Genetic testing was negative for primary oxaluria (AGXT, GRHPR, and HOGA1). Beekeeping is becoming a popular hobby, and vaporized oxalic acid (some in the form of wood bleach purchased in hardware stores) combined with ethanol permeates bee hives. While not affecting the bees, the formulation kills the Varroa mite, which is a parasite that can feed on the bees and their brood causing significant harm and even colony death. Public health awareness may avoid accidental and intentional ingestion by communities at risk, including children and adolescents.

Bonus finding:

A venular microthrombus, which is not an uncommon finding in young patients with dehydration, usually following ingestion of large amounts of ethanol.