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Ant Allergens and Hypersensitivity Reactions in Response to Ant Stings

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Ant Allergens and Hypersensitivity Reactions in Response to Ant Stings Review article Ant allergens and hypersensitivity reactions in response to ant stings Rutcharin Potiwat1 and Raweerat Sitcharungsi2 Summary Keywords: Allergy, ant stings, hypersensitivity, immunotherapy, treatment Hypersensitivity reactions caused by ant stings are increasingly recognized as an important Introduction cause of death by anaphylaxis. Only some species Ants are insects and belong to the order of ants ( e.g. Solenopsis spp., Myrmecia spp., and Hymenoptera and the family Formicidae. There are Pachycondyla spp.) cause allergic reactions. Ant currently more than 12,500 ant species known. species are identified by evaluating the morphologic Although some species of ants can bite and sting structures of worker ants or by molecular humans, only some ant genera, such as Solenopsis, techniques. Ant venom contains substances, especially S. invicta and S. ricteri (commonly known as including acids and alkaloids, that cause toxic imported fire ants), cause life-threatening allergic reactions, and those from Solenopsis invicta or reactions. Ant hypersensitivity is one of the most the imported fire ant have been widely studied. important causes of severe systemic reactions or Piperidine alkaloids and low protein contents can anaphylaxis with reports of fatalities from ant cause local reactions (sterile pustules) and anaphylaxis occurring worldwide in both urban and systemic reactions (anaphylaxis). Imported fire rural areas. The diagnosis of ant hypersensitivity can ant venoms are cross-reactive; for example, the be performed by allergic history and physical Sol i 1 allergen from S. invicta has cross- examination of the ant sting, or by in vivo and in reactivity with yellow jacket phospholipase. The vitro tests. The management of ant hypersensitivity Sol i 3 allergen is a member of the antigen 5 can be divided into immediate treatment for family that has amino acid sequence identity with anaphylaxis, and preventive treatment. However, vespid antigen 5. The clinical presentations of ant knowledge of ant-induced allergic reactions in some hypersensitivity are categorized into immediate parts of the world is limited. This article reviews ant and delayed reactions: immediate reactions, such diversity and distribution, the medical importance of as small local reactions, large local reactions, and ant stings, ant allergens, and their cross-reactivity, as systemic reactions, occur within 1–4 hours after well as the clinical presentations and management of the ant stings, whereas delayed reactions, such as ant hypersensitivity reactions. This information will serum sickness and vasculitis, usually occur more enhance the basic knowledge of ants for scientists than 4 hours after the stings. Tools for the and provide an overview of therapeutic guidelines diagnosis of ant hypersensitivity are skin testing, for physicians. serum specific IgE, and sting challenge tests. Management of ant hypersensitivity can be Ant diversity and distribution divided into immediate (epinephrine, corticosteroids), Ants are social insects classified in the family symptomatic (antihistamines, bronchodilators), Formicidae, order Hymenoptera. Ants are diversely supportive (fluid resuscitation, oxygen therapy), spread among continents and biogeographic regions and preventive (re-sting avoidance and with more than 12,500 species in 290 genera immunotherapy) treatments. (Asian Pac J Allergy belonging to 21 subfamilies having been identified Immunol 2015;33:267-75) thus far. Tropical areas and continental forests have the greatest influence on the presence of ant species From 1. Department of Medical Entomology, Faculty of diversity. In Thailand, 247 ant species distributed Tropical Medicine, Mahidol University, Bangkok, Thailand among 55 genera in nine subfamilies have been 2. Department of Tropical Pediatrics, Faculty of Tropical recorded.1-4 Six of these species (Aenictus artipus, Medicine, Mahidol University, Bangkok, Thailand Leptanilla thai, Lophomyrmex striatulus, Tetramorium Corresponding author: Raweerat Sitcharungsi ciliatum, Tetramorium flavipes, and Tetraponera E-mail: [email protected] Submitted date: 11/12/2015 267 Asian Pac J Allergy Immunol 2015;33:267-75 notabilis) were originally described from Thai territories stings. Both T. rufonigra and O. denticulata have a and are located in agricultural fields and forests.5 stinger at the end of the gaster (Figure 2). T. Invasive ants are exotic species that establish rufonigra-induced hypersensitivity has been colonies outside their native areas and can cause a reported in humans after stings and can cause severe decline or a change in diversity, community, and anaphylaxis.18 The first case of T. rufonigra-induced populations of native invertebrates, vertebrates, and anaphylaxis was reported from Thailand. The patient plants by their invasion and displacement.6 was a 17-month-old girl who presented with two However, invasive ant species, such as Solenopsis episodes of urticaria, angioedema, dyspnea, and loss geminata and Tetraponera rufonigra, can also play of consciousness.7 an important role in the impact on clinical Species identification of the most common causative hypersensitivity reaction.7, 8 The important invasive species of ant anaphylaxis in Thailand ant species are widely distributed worldwide (Table The most common causative species of ant 1).9-11 Of these invasive ant species, Anoplolepis anaphylaxis in Thai patients are Solenopsis geminata, gracilipes (yellow crazy ant), Pheidole megacephala Tetraponera rufonigra, and Odontoponera denticulata. (big-headed ant), and Solenopsis geminata (tropical S. geminata belongs to the family Formicidae, fire ant) are all present in Thailand.6 The yellow subfamily Myrmicinae, genus Solenopsis, species crazy ant is thought to decrease the diversity and geminata. The morphology of Solenopsis can be population of native fauna and flora in ecosystems confused with a smaller species of Monomorium, due to its replacement of natural native species, but although Solenopsis is distinguished by the presence information on its distribution is rarely reported. of a two-segmented petiole.19, 20 Identification of fire The medical importance of ant-induced hypersensitivity ant species is very difficult and involves evaluating Thailand has a number of ants of medical the morphology of worker ants rather than just one importance. The red imported fire ant (Solenopsis specimen. S. geminata workers have a polymorphic invicta, Buren) is an important invasive ant species size of 3–8 mm body length. The body has a reddish that is also present in many other parts of the world, brown color and is mostly smooth and shiny, and is considered to cause hypersensitivity in both without sculpture. The head of the S. geminata children and adults. Other fire ants in the genus worker is divided into two notches, while in S. Solenopsis, including S. invicta, S. richteri, S. invicta workers these notches are absent (Figure 2). geminata, S. saevissima, S. xyloni, and S. aurea can The differentiation of tropical fire ant morphology is cause allergic reactions.10, 12 Importantly, there is determined using worker ants but can also be cross-reactivity among venoms of the Solenopsis characterized using molecular techniques based on species, such as S. xyloni and S. aurea, and other mitochondrial DNA encoding cytochrome oxidase hymenoptera.13, 14 The tropical fire ant (S. geminata) subunit I (COI) or the internally-transcribed spacer is a natural native species with a wide distribution (ITS) gene.21 The differentiation of Solenopsis species throughout Thailand whose stings can cause allergic by morphology alone is difficult and can often be reactions. Another group of ants that cause confused with other species; therefore, molecular hypersensitivity belong to the genus Myrmecia, identification is now widely used. PCR especially M. pilosula, which are found in amplification of the COI gene followed by cutting Australia.15-17 However, the ant species that are most nucleotide sequences with the HinfI restriction commonly responsible for anaphylaxis in Thai enzyme can be used to distinguish S. invicta, S. patients are Solenopsis geminata, Tetraponera geminata, and S. xyloni from Florida.22 However, rufonigra, and Odontoponera denticulata (Figure 1). even though molecular amplification is now widely Patients with stings from these ants were referred to used, it is expensive. tertiary care hospitals in Bangkok for T. rufonigra belongs to the family Formicidae, immunotherapy, and ants were sent for species subfamily Ponerinae, genus Tetraponera, species identification at the Faculty of Tropical Medicine, rufonigra. It is black and shiny except on their Mahidol University (unpublished data). All three alitrunk that has an orange line, which is the specific species are aggressive ants with painful bites or characteristic of T. rufonigra. Differentiation of 268 Hypersensitivity to ant stings Table 1. The geographical distribution of major invasive ant species. Ant species Geographical Range Reference(s) Native Invasive species Anoplolepis gracilipe* Africa, Tropical Africa, Asia, Australia, Caribbean, Indian and Pacific 91 (Yellow crazy ant) Asia? Ocean Dinoponera gigantea Amazonian states 92 Hypoponera sp. Brazil, Malaysia 93, 94 Linepithema humile South America, Africa, Asia, North America, Atlantic and Pacific 95, 96 (Argentine ants) Argentina Ocean, North Carolina (US) Myrmecia pilosula Far East, Australia 47, 66, 71 Odontomachus bauri Caracas, Venezuela 71, 97 Pachycondyla chinensis (Chinese
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