Q:

5/1/2014
The patient is an 18 year-old male applying to the military who has h/o 3 large local reactions to stinging insects that involved eye/facial swelling during his elementary school years. There were no systemic sxs. After the 3rd reaction, PMD prescribed an epi pen. Mom states he has not carried it since middle school and they have never used it.
He was stung several times by honey bees 2 years ago while working on his uncle's HB farm with no systemic or local reaction.

IgE specific test to venoms was ordered by PMD recently with following results:
HB IgE: 14.9
Yellow Jacket: 2.84
White-faced hornet: 3.75
Yellow-faced hornet: 2.94
Wasp: 1.07

Military won't allow epi pens in basic training. I know there is a 5-10% chance of pts having systemic reactions with h/o large local reactions and I probably would not have ordered Immunocap testing. Now that I am at this point, is there further workup warranted for this patient (skin test) and how would you advise patient at this point?

A:

Thank you for your inquiry.

In direct answer to your question, in my opinion no further workup is indicated at this time. The advice that you give to the patient is entirely discretionary based upon your assessment of risk/benefit ratio and the desire for the patient to enter the military. The reason I say this is that the prescription of an automatic epinephrine injector to a patient with large local reactions is left to the discretion of the physician caring for the patient. There is no mandate to do so, and there are differences in opinion in the Allergy community regarding the practice of prescribing automatic epinephrine injectors to this population.

Therefore, since the practice is not standardized, I can only give you an opinion. And the strategy that I would pursue in this instance would be to discuss the risk/benefit ratio and pros and cons with your patient. If he wishes to enter the military and is aware of the issues involved, I would personally favor allowing him to do so even in the absence of his ability to carry an automatic epinephrine injector during the period of basic training.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology