REVIEW
Fire Ant Attacks on Patients in Nursing Homes:
An Increasing Problem
Richard D. deShazo, MD, Stephen F. Kemp, MD, Matthew D. deShazo, Jerome Goddard, PhD
We review the medical reports of fire ant attacks on residents of
nursing homes in the context of the medical entomology of
these insects, and present recommendations to prevent and
manage future attacks. Two reports were recent cases, while a
computer-assisted search yielded four other similar cases of at-
tacks by foraging fire ants in the last 10 years. One patient expe-
rienced an anaphylactic reaction and 4 patients died within 1
week of the attack. Ants were usually noted in health care facil-
ities days before the attacks. The presence of fire ants around
immobile, often cognitively impaired, patients seems to be the
O
ver the last 10 years, we have published a series of
articles describing the biology and entomology
of, and medical consequences of stings from, im-
ported fire ants, namely, Solenopsis richteri, Solenopsis in-
victa, and their hybrid S. invicta x richteri (1). As the hab-
itat and density of fire ants have expanded from the
Southeast to Virginia and west to California, 80 cases of
fatal anaphylaxis have been reported (Figure 1). In almost
all of these cases, healthy persons, who had disturbed the
ground-nesting, mound-building ants during routine ac-
tivities such as walking, golfing, or simply sitting on the
ground, experienced sting attacks that resulted in ana-
phylaxis (2,3). Recently, we chronicled a novel behavior
of these ants: foraging inside health care facilities, primar-
ily nursing homes, with subsequent massive sting attacks
on patients with impaired consciousness (4 – 6).
In this paper, we report two more fire ant attacks on
residents of nursing homes: one in Florida and the other
in Texas. Because of the continued geographic expansion
of these ants and the increasing density of their popula-
tions in endemic areas, more of these episodes are likely
unless health care professionals become better informed
about the biology of these insects.
From the Division of Allergy and Immunology (RDD, SFK, MDD);
Department of Medicine, University of Mississippi Medical Center,
Jackson; and Bureau of General Environmental Services (JG), Missis-
sippi Department of Health, Jackson, Mississippi.
Requests for reprints should be addressed to Richard D. deShazo,
MD, Department of Medicine, University of Mississippi Medical
Center, 2500 N. State Street, Jackson, Mississippi 39216, or
rdeshazo@medicine.umsmed.edu.
Manuscript submitted August 4, 2003, and accepted in revised form
February 26, 2004.
© 2004 by Excerpta Medica Inc.
All rights reserved.
primary risk factor for massive fire ant attacks. Health care pro-
viders and administrators in fire ant endemic areas must be
aware that the presence of fire ants in hospitals and nursing
homes represents a hazard. Fire ant infestation can lead to sting
attacks on patients, causing respiratory tract obstruction, wors-
ening of pre-existing medical conditions, or frank anaphylaxis.
All the attacks reported here have resulted in legal action involv-
ing physicians and health care facilities. Am J Med. 2004;116:
843– 846. ©2004 by Excerpta Medica Inc.
METHODS
We reviewed all available personal medical records re-
lated to the fire ant attacks on these two patients. Avail-
able case reports of other fire ant attacks of patients in
health care facilities were obtained and reviewed using
MEDLINE searches of the literature published in English
from 1966 to March 2003. Colleagues in the entomology
and allergy professional communities were also con-
sulted for case reports that were not readily available
through MEDLINE. This review was approved by the In-
stitutional Review Authority of the Mississippi Depart-
ment of Health.
REVIEW OF NEW AND PREVIOUSLY
REPORTED CASES
We found reports of fire ant attacks of persons residing in
private homes and health care facilities (4 –9). A 5-day-
old infant who had been stung at home had a near-fatal
response, whereas a 26-month-old toddler developed
corneal opacities (7,8). The death of a 3-month-old in-
fant owing to numerous fire ant stings in an upscale sub-
division of Phoenix, Arizona, was recently reported in the
lay press (10). At least 2 healthy adults and 1 patient with
Alzheimer’s disease who had been stung at home have
survived fire ant attacks without sequelas (6,9).
We reviewed the medical records of two recent, previ-
ously unreported attacks involving nursing home pa-
tients (Table). The first patient was a 72-year-old male
nursing home resident in central Florida who was found
covered with fire ants and complaining of “being hot”
during a 1:30 AM bed check. His tongue rapidly became
0002-9343/04/$–see front matter 843
doi:10.1016/j.amjmed.2004.02.026
 Fire Ant Attacks in Nursing Homes/deShazo et al

Figure 1. Quarantine map reflecting the current distribution of imported fire ants in the United States. Transport of certain
agriculture products that may contain fire ant colonies is regulated in these areas. Reprinted courtesy of the U.S. Department of
Agriculture. Available at: http://www.aphis.usda.gov/ppq/maps/fireant.pdf.

swollen and within minutes he suffered a cardiopulmo-
nary arrest. He was resuscitated and taken to a hospital
where his serum tryptase level 1 hour later was 23 ng/mL
(reference range, ⬍11 ng/mL), documenting the clinical
impression of anaphylaxis. He improved after initial
treatment with parenteral antihistamines and corticoste-
roids, but subsequently developed progressive respira-
tory failure and died less than 24 hours after the sting
attack.
The second patient was an 85-year-old female nursing
home resident in south Texas who was found covered
with fire ants during a 4:00 AM bed check. Like the first
patient, she was also treated with parenteral antihista-
mines and corticosteroids. She developed adult respira-
tory distress syndrome within 8 hours of the attack and
died 3 days later. In both of these cases, fire ants had been
noted in patient care areas prior to the attacks.
Of the six reported cases of massive fire ant stings in a
health care facility (Table), only one involved an anaphy-
lactic reaction and only 1 patient faired well after massive
stings. That patient (patient 3) was in good general
health, except for Alzheimer’s disease, and had no obvi-
ous health effects (4). Four patients died within 1 week of
the attacks: 2 had worsening of pre-existing cardiopul-
monary insufficiency, 1 developed acute respiratory dis-
tress syndrome, and 1 had a cardiopulmonary arrest. The
fifth patient (patient 6) who had been bed bound with
multiple health problems, including severe congestive
heart failure, had progressive deterioration and died 13
months later.
IMPLICATIONS FOR HEALTH CARE
FACILITIES
Residents of health care facilities in fire ant endemic areas
are at risk of fire ant attacks when they are immobile or
cognitively impaired, and when there is an infestation at a
facility that lacks the appropriate pest control techniques
for fire ants. Health care personnel are often unaware of
the behavior of these insects and the special measures
required for their control. Moreover, they often misiden-
tify fire ants as nonstinging domestic ants.
Fire ant mounds typically contain 80,000 to 250,000
workers, one or more queens that live for 2 to 6 years and
produce about 1500 eggs daily, and variable numbers of

844 June 15, 2004 THE AMERICAN JOURNAL OF MEDICINE威 Volume 116
 Fire Ant Attacks in Nursing Homes/deShazo et al

Table 1. Reports of Indoor Fire Ant Attacks on Residents of Nursing Homes

Nursing
Patient Age Type of Home
No. (years) Sex Health Status Reaction Location Clinical Consequences Reference
1 72 M Quadriplegia, chronic Pustules, Florida Anaphylaxis with Present report
obstructive lung disease anaphylaxis cardiopulmonary arrest,
death 24 hours later
2 85 F L1 compression fracture Pustules Texas Aspiration pneumonia, Present report
on narcotic analgesia, cardiorespiratory failure,
dysphagia acute respiratory distress
syndrome, death 4 days later
3 74 F Alzheimer’s disease Pustules Florida None (4)
4 90 F Multi-infarct dementia, Pustules Texas Worsened heart failure, (5)
heart failure, respiratory respiratory insufficiency,
insufficiency death 6 days later
5 67 F Dementia, heart failure, Pustules Mississippi Worsening of (6)
respiratory insufficiency cardiopulmonary failure,
death 5 days later
6 60 M Hemiparesis, dysarthria, Pustules Mississippi Heart failure, further loss of (6)
dysphagia, incontinence function, death from sepsis
13 months later
F ⫽ female; M ⫽ male.

male winged reproductives (11). Fire ant workers are eas-
ily identified by their mound building in nonsandy soils,
color (yellow-red to brown-black), size (1/16 to 1/4 inch),
and sting behavior when disturbed (Figure 2). When dis-
turbed, fire ants first attach to the intruder using their
powerful mandibles, then they bend their abdomens in a
copulatory-like motion and thrust the stingers that are
located on the distal abdomen into the intruder. If the
intruder happens to be human, the introduction of
venom into the skin causes immediate severe pain, burn-
ing and itching, an immediate local area of erythema at
the sting site, and a characteristic sterile pustule that de-
velops at the sting site 24 to 48 hours later. Ants usually
remain attached to the skin during the sting process, and
since the pain is almost instantaneous, stinging ants are
usually visualized and brushed off by unimpaired per-
sons.
Pesticides ordinarily used to control the usual indoor
pests are not effective against fire ant infestation as they
do not kill the fertile queen (12), which remains seques-
tered in the nest, often at a long distance from the forag-
ing worker ants. Service contracts with pest control com-
panies are frequently ambiguous about both company
and facility responsibilities. Moreover, these contracts
sometimes fail to provide for pest control outdoors, the
natural habitat of fire ants. Ant colonies may move closer
to or into occupied buildings under special circum-
stances, such as drought, flooding, cold, or high density of

Figure 2. Typical fire ant colony (mound) at the base of concrete blocks (left)*. Fire ants on the hand of a volunteer (center)*; some
are actively stinging. Imported fire ants vary in size on the basis of their caste and in color from red to black (left).† The large ant on
the far right is a queen. Although some ants are small enough to be confused with native species, they are easily differentiated as all
fire ants sting any object immediately when disturbed. *Photographs by Jerome Goddard, PhD. †Reprinted with permission from the
Texas Department of Agriculture; photograph by S. D. Porter.

June 15, 2004 THE AMERICAN JOURNAL OF MEDICINE威 Volume 116 845
 Fire Ant Attacks in Nursing Homes/deShazo et al
colonies (13). Once fire ants are detected in a facility,
facility personnel often have no formal procedures to re-
port and expeditiously eliminate infestation.
In the case of medical facilities, worker ants may ex-
plore patient rooms and patients themselves in their
search for food. Imported fire ants ingest, among other
things, sugars, some amino acids, and oils containing
polyunsaturated fats in liquid form. When disturbed in
their feeding process by movement or vibration, ants that
are in close contact with patients may sting these patients
multiple times. Animal studies support the observation
that confined subjects with alterations of sensation or
consciousness or tethering by medical devices are at spe-
cial risk of injury by foraging fire ants. One study showed
that 19% of cotton rats captured in traps that had been set
in fire ant endemic areas 6 hours previously were attacked
by ants. Of the 33 rats attacked, 20 were dead and covered
with ants, and 13 were alive and partially eaten when
found (14).
The clinical sequelas of massive fire ant stings relate to
the biologic activity of the ant venom, which possesses
hemolytic, neurotoxic, and cytotoxic activity (1,15); in-
hibits sodium and potassium adenosine triphosphatases;
reduces mitochondrial respiration; uncouple phosphor-
ylation; adversely affects neutrophil and platelet function
(16,17); inhibits nitric oxide synthetase (18,19); and per-
haps activates coagulation (3,4,17). These properties pre-
dispose to a hypercoagulable state and exacerbate any al-
lergic symptoms experienced by patients who are
attacked (20).
Since there are presently no methods to stop the geo-
graphic expansion of imported fire ants, our group has
published extensive recommendations for the prevention
and management of fire ant infestation in health care fa-
cilities, as well as the emergency management of massive
fire ant stings (12). Medical facilities in fire ant indige-
nous areas should have pest control contracts that specify
monthly inspections of the grounds and the interior of
the facility, with treatment as required and emergency
service when requested. Facility personnel should inspect
grounds on a weekly basis. When ants are noted within 25
feet of the building, perimeter treatment should be ap-
plied within 24 hours and the interior of the building
should be inspected. When fire ants are noted in the in-
terior of the building, patient rooms and all other areas
should be inspected. If ants are noted in a patient’s room,
the patient should be removed from the room, and the
area should be treated by a competent pest control service
with pesticides and baits approved for indoor use and
reinspected frequently. In addition to native infestations
in South America and their expanding habitat in North
America and Puerto Rico, fire ant colonies have also re-
cently been detected in Australia (21). Accordingly, per-
sonnel in health care facilities in these areas should be
846 June 15, 2004 THE AMERICAN JOURNAL OF MEDICINE威 Volume 116
aware of the risk to patients posed by these insects and of
the various ways to control infestations.
ACKNOWLEDGMENT
The authors wish to thank Ms. Dawn Chism for assistance in the
preparation of this manuscript.
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