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Fire ant allergy

Question:

8/15/2017
Recently evaluated an 18 year-old male patient with a history of a systemic reaction to a fire ant sting during infancy. Patient sustained 6-7 stings and an hour later, developed generalized urticarial and facial swelling, Blue lips but no respiratory distress. Some vomiting later. Responded promptly to therapy in the ER. Was subsequently tested during childhood and was on immunotherapy for about two years (records not available).

After immunotherapy course, the patient has had about ten separate sting episodes, including recent stings and has had no reaction. Recent ImmunoCap to IFA revealed a level of 1.82 KU/L. (Patient leaving for college and couldn't schedule IFA skin testing.)

The patient would like to join the ROTC and eventually become an Army Ranger. Does the current history trump the ImmunoCap result? What would you tell the Army medical review staff regarding IFA allergy status?

Answer:

I thank Dr Ted Freeman for his response to your inquiry.

Clearly this patient had a mild systemic reaction during infancy to a fire ant sting. He was appropriately evaluated and placed on fire ant whole body extract immunotherapy. After 2 years his immunotherapy was stopped and he has had multiple stings since that time all reported to be without reaction. My recommendation at the time of starting the immunotherapy would have been to continue immunotherapy for 3 to 5 years then stop. However shorter courses of immunotherapy have sometimes proven to provide long term protection, and this appears to be the case here, where the patient has suffered multiple stings without symptoms. The Immunocap reflects that he has continued to be stung but the history is the most important data here. So I would tell the army that he had a mild systemic reaction as an infant and had an adequate course of immunotherapy and needs no additional therapy at this time.

I would offer a word of caution. I have answered this on the basis of taking the history at face value, which is what I do with most patients. Experience has taught me that it is not unusual for highly motivated people to selectively remember or not remember history based on what they hope to attain such as entry to the military. Every effort needs to be made to assure yourself that the history is as given such as verification with other family members and review of prior records ("records not available" is always a little suspicious).

In addition, I always counsel in these cases that a decision on commissioning or enlistment is an administrative decision. Regulations governing what prevents commissioning or enlistment, while based on medical recommendations, purely reflect the needs of the service and are subject to change at any time. How the regulations are interpreted are subject to change as well. Consequently someone might accept the opinion I wrote above and allow commissioning or enlistment on one day and on another decide that the patient needs to have 3-5 years of immunotherapy before commissioning or enlistment.

I hope that helps

Jacqueline A. Pongracic, MD, FAAAAI