Indications for an automatic epinephrine injector in an individual applying for military service
Question:
8/20/2012
4/12/2018
I recently saw an 18 year old black male who wishes to enter the military, but the recruiting office said if he needs Epi pen for insect sting allergy or any reason he may be disqualified. He has no history of asthma. Six years ago he was stung on his neck. Shortly after being stung he had SOB, face and neck swelling. No nausea/vomiting/diarrhea. He did admit to some throat closure with difficulty talking and breathing. He lost consciousness which caused him to fall out of the tree, and was sent to a hospital where he was given Epi and released, and never referred to an allergist. He had not been previously treated for stinging insects.
Our insect venom skin and Immunocap sent to Labcorp were all negative for this patient for all 5 stinging flying insects. Please advise. If Epi-pen is required to be prescribed after 6 years from his reaction despite negative skin & blood testing, it could disqualify him from the military. I believe the updated guidelines don't seem to be clear on indications for Epi in negative stinging insect tested patients- is this correct? What about the passage of 6 years, is this relevant in this case as well as far as the possibility of loss of reactivity? What should we tell the patient? Thanks for your opinion.
Answer:
Thank you for your inquiry.
Unfortunately, as you know, there is no "evidence-based" answer, at least to my knowledge, to your inquiry. The issue is one of clinical judgment, and I personally do not feel there is a "right or wrong" way to approach this problem.
One way to look at this issue is ask yourself if you would give this individual an automatic epinephrine injector to keep with him were he not applying for the military. In this instance, I must admit, I would do so. The question then becomes whether or not his application to the military is such a strong mitigating factor that one would consider altering that recommendation in order to support what would be a worthy endeavor. I cannot give you an answer except to cite what we have done in the past with similar cases.
I usually write a very strong letter of support, stating clearly that you found no evidence of insect sting sensitivity, and therefore the risk for a reaction would be extremely small, probably bordering on negligible. In addition, I usually state quite clearly that I would support his application. Nonetheless, I also add in such cases, regardless, that we would normally request that an automatic epinephrine injector be available to him.
Since this is an issue without a definitive answer, I am also going to ask Dr. Robert Reisman, who has published extensively in the area of insect sting reactions, and who has multiple years of clinical experience in dealing with such reactions, to give us his opinion and his personal strategy as to how he might approach this problem. It may differ entirely from mine, but if so, it will give you further information upon which you may base your own personal decision as to how to approach the issue. When I hear from Dr. Reisman, I will forward his response to you.
Thank you again for your inquiry.
Sincerely,
Phil Lieberman, M.D.
We received a response from Dr. Robert Reisman. Thank you again for your inquiry and we hope this response is helpful to you.
Sincerely,
Phil Lieberman, M.D.
Response from Dr. Robert Reisman:
The negative venom skin tests and in vitro tests should be interpreted to indicate that the individual is not allergic to insect stings at this time. Mast cell disease needs to be ruled out, [serum tryptase] to exclude a non-immunological etiology for venom induced reaction. A bumblebee sting reaction would be a very remote consideration-the venom is only partially cross-reactive with honey bee venom. I am not sure if an in vitro test is available.
If mastocytosis is excluded, I do not believe the individual is at risk for a systemic sting reaction. I would so notify the military service. I do not believe an Epi- Pen availability is needed or advisable. [If you so advise, for how long?]
I assume there have been no interval tolerated stings.
Best regards,
Bob Reisman