Case report of an aviator with a single episode of altered consciousness due to hymenoptera hypersensitivity

This case is presented to: a) emphasize the importance of a careful history , including interviewing witnesses and considering a complete differential diagnosis when evaluating aviators with a history of an episode of altered consciousness; and b) demonstrate an appropriate use of literature review, subspecialty consultations, and U.S. Air Force Aeromedical Guidelines to ar rive at an aeromedical disposition for an unusual case. A military aviator experienced an episode of syncope/near syncope, initially felt to be caused by a primary seizure or an arrhythmia. Subsequent thorough evaluation incl uded careful history taking, extensive interviewing of witnesses, subspecia lty consultations, review of appropriate literature and deliberation by a b oard of experienced military aeromedical physicians. Cardiac and neurologic diagnoses were considered but careful history and witness interviews revea led that the aviator had sustained an insect sting just minutes before the episode. Evaluation by allergy specialists, including skin testing, identif ied him as being hypersensitive to Hymenoptera stings. A diagnosis of hyper sensitivity reaction to a Hymenoptera sting was determined to be the cause of the altered consciousness episode. Review of the literature revealed tha t immunotherapy for Hymenoptera sensitivity reduces the risk of future anap hylaxis to only 1-2% after maintenance dose is achieved. Consideration of t he risk of future events and the success of rush immunotherapy resulted in a recommendation for a waiver to return the aviator to unrestricted flying duties. The importance of diligent history taking must never be forgotten. In this aviator it led to the correct diagnosis and definitive therapy. in addition, appropriate consideration of the literature and knowledge of outc ome rates allowed a return to unrestricted flying for this aviator. If the original diagnosis of seizure or arrhythmia had been accepted, this aviator would have been disqualified without waiver and a valuable flying asset wo uld have been lost.