Diagnostic and Therapeutic Approach in Patients with Exercise-Induced Anaphylaxis

Abstract

The prevalence of exercise-induced anaphylaxis is estimated to be about 2.36-5 % of all cases of anaphylaxis. The clinical manifestations of exercise-induced anaphylaxis include flushing, increase warmth, diffuse pruritus, urticaria, angioedema, bronchospasm, gastrointestinal symptoms, hypotension, and laryngeal edema. The main differential diagnosis is with cholinergic urticaria. Exercise-induced anaphylaxis may display food-dependence, with or without specific IgE sensitivity. The most commonly implicated foods are wheat (omega-5 gliadin), shellfish (especially shrimps), celery, corn, cow’s milk, mite-contaminated wheat flour, and peanuts. Interestingly, in these patients aerobic exercises alone, as well as the sole ingestion of the allergenic foods without associated exercises, do not cause anaphylaxis. The synergistic effect of both inducing factors is necessary for the occurrence of the anaphylactic manifestations. There may be drug-dependence in exercise-induced anaphylaxis. Implicated drugs and chemicals include NSAIDS, aspirin, antibiotics (cephalosporins), and the so-called anti-catabolic energizer supplements, such as beta-hydroxymethylbutyrate. Avoidance of eating the triggering foods is recommended when possible, and in temperate areas of the planet an additional preventive measure is not to exercise when there is high environmental exposure to pollens (then exercising indoors). It is also advisable to avoid exercising in extreme weather conditions (too hot, cold, or humid environments). Monoclonal anti-IgE (omalizumab) as a mast cell stabilizer with downregulation of the high affinity IgE receptors (FceRI) can have a potential role preventing these anaphylactic episodes.