Diagnosis Of Food-dependent Exercise-induced Anaphylaxis Research Articles

YOU CAN RUN BUT YOU...CAN HIVE!

Introduction Food-dependent, exercise-induced anaphylaxis (FDEIAn) is characterized by anaphylaxis which occurs only after the patient exercises within hours of eating. This is a case of tomato-dependent, exercise-induced anaphylaxis. Figure. Reactions of Episodes 1 and 2. (Episode 1) Generalized urticaria and face angioedema of episode 1 and generalized urticaria of episode. (Episode 2) The pictures were taken less than 5 minutes after onset of symptoms and prior to self-treatment with H1 and H2 antihistamines. Case description A 15-year-old male without any history of allergies reported three episodes of anaphylaxis in a three-month period. In all episodes, symptoms included generalized urticaria, swelling of the eyes and lips, lightheadedness, runny nose, nausea, and throat itching. Episodes 1 and 2 began 10-30 minutes after he started jogging and having eaten approximately 2 hours earlier. Both events resolved after self-treatment with diphenhydramine and famotidine. Episode 3 started after running 50-75 yards and eating 8 hours prior to exercising. This time he visited the ED where a 10.4 tryptase level was drawn (baseline 3; ref He ate tomato before each episode in pizza, pulled pork, and fresh tomatoes respectively. He denied any symptoms with tomatoes and exercise alone, chronic urticaria, GERD, and exposure to alcohol and NSAIDs. The patient had positive skin-prick testing to tomato and negative to all other common food allergens including prick-prick testing. He was prescribed epinephrine auto-injectors and recommended to avoid tomato at least 8 hours before exercising, training with partners who know of condition. Discussion Diagnosis of FDEIAn is made in patients with anaphylaxis during or shortly after exercise preceded by food ingestion, evidence of specific IgE to the implicated food, and absence of an alternate diagnosis for the clinical presentation. This patient meets criteria for anaphylaxis, was exposed to tomato in all episodes, and had positive skin-testing.

Surveillance of the use of adrenaline auto-injectors in Japanese children

BackgroundThe appropriate usage of an adrenaline auto-injector (AAI, Epipen®) is a key aspect of patient and social education in the management of anaphylaxis. However, although AAIs are being prescribed increasingly frequently, there are few reports on their actual use. MethodsThe Anaphylaxis Working Group of the Japanese Society of Pediatric Allergy and Clinical Immunology requested that society members register cases in which AAIs were used. Two hundred and sixty-six cases were collected from March 2014 to March 2016. ResultsThe cases included 240 events of immediate-type food allergies caused by cow's milk (n = 100), hen's egg (n = 42), wheat (n = 40), and peanuts (n = 11). Exercise-related events were reported in 19 cases; however, the diagnosis of food-dependent exercise-induced anaphylaxis with a specific causative food was only made in 4 cases (wheat, n = 2; fish, n = 1; squid, n = 1). The frequent reasons for the causative intake included programmed intake (n = 48), failure to check the food labeling (n = 43), and consuming an inappropriate food (n = 26). AAIs were used at schools or nurseries in 67 cases, with school or nursery staff members administering the AAI in 39 cases (58%). On arriving at the hospital, the symptom grade was improved in 71% of the cases, while grade 4 symptoms remained in 20% of the cases. No lethal cases or sequelae were reported. ConclusionsAAIs were used effectively, even by school teachers. The need to visit a hospital after the use of an AAI should be emphasized because additional treatment might be required.

食物依存性運動誘発アナフィラキシーの診断におけるアレルゲンコンポーネントの有用性

「食物アレルギー診療ガイドライン2016」では, 食物依存性運動誘発アナフィラキシー (FDEIA) の診断に, 詳細な問診, 一般的血液検査, 各種アレルギー検査が有用で, 確定診断には誘発試験の実施が望ましいとされている. しかし誘発試験の再現性は高くはなく, アレルゲンコンポーネント (AC) が新たな診断ツールとして注目されている.

食物依存性運動誘発アナフィラキシーの臨床経過と原因食品ごとの診断ポイント

食物依存性運動誘発アナフィラキシーの臨床経過と原因食品ごとの診断ポイント

Food-dependent exercise-induced anaphylaxis in Korea: a multicenter retrospective case study

Purpose: To investigate the causes, clinical features and characteristics of food-dependent exercise-induced anaphylaxis (FDEIA) in Korea. Methods: A retrospective medical chart review was performed on the patients diagnosed with anaphylaxis between 2007 and 2011 in 14 hospitals in Korea. Cases with FDEIA were subsequently identified among anaphylaxis patients, and subgroup analyses were done to assess clinical characteristics of FDEIA. Results: A total of 62 subjects with FDEIA (male, 72.6%; aged 16 to 70 years) were enrolled in 10 hospitals. Wheat (69.3%) was the most common cause of FDEIA, followed by meat (8.1%), seafood (6.5%), and vegetables (6.5%). The clinical manifestations were cutaneous (100%), respiratory (64.5%), cardiovascular (61.3%), and gastrointestinal (9.7%), respectively. In severity assessment, approximately 40% of FDEIA were classified as severe anaphylaxis. Portable epinephrine auto-injector was prescribed to 17.2% of patients, and about one fifth of the patients experienced redevelopment of anaphylactic symptoms during follow-up period. There was no significant difference of age, gender, latent period, total immunoglobulin E, and past history of allergic disease between patients with severe anaphylaxis group and patients with mild-to-moderate group. Conclusion: Wheat is the most common cause of FDEIA in Korea. Because significant number of patients with FDEIA experienced anaphylactic symptoms after diagnosis of FDEIA, more comprehensive therapeutic and educational approaches will be required to prevent recurrent development of anaphylaxis. (Allergy Asthma Respir Dis 2013;1:203-210)

Managing exercise food induced anaphylaxis

Food dependent exercise induced anaphylaxis (FDEIA) is an IgE mediated adverse reaction to specific foods, where symptoms only appear in combination with physical activity. In absence of exercise, subjects with FDEIA tolerate the offending food. FDEIA can, as the nomenclature indicates, be life threatening, but most common symptoms are urticaria, flushing, pruritus and angioedema. The mechanism behind FDEIA is unclear, but a number of hypotheses have been proposed, such as altered GI permeability, blood distribution or activation of mucosal mast cells. Managing FDEIA is characterized by avoidance of the offending food in combination whit physical activity. However, in order to give proper guidelines for managing FDEIA, a precise diagnosis is crucial. The diagnosis of FDEIA is based on case history, relevant sensitization, exclusion of cholinergic urticaria and “regular” non-exercise induced food allergy and finally reproduced by an exercise test. Different foods are known to elicit FDEIA, wheat being the most common. The aetiology of wheat dependent exercise induced anaphylaxis (WDEIA) is better understood than symptoms caused by other allergens. The wheat protein component Ω-5 Gliadin is known to be involved in WDIEA, but the precise role, clinical relation and relevance of in-vivo/vitro measurement is unclear. Further, the type and intensity of the exercise as well as the kinetics and time perspective need further focus. Food processing such as heat treatment, cooking and baking also influences the diagnosis and thereby the management of exercise induced food anaphylaxis. Standard diagnostic procedure in order setting include initial careful case history followed by skin prick testing with various wheat extracts, measurement of specific IgE to wheat and available wheat components followed by a histamine release from basophils, stimulated with a variety of raw and processed wheat preparations. Ultimately, a standardised treadmill exercise is performed.

운동 유발성 알레르기 질환(FDEIA)에 미치는 영향과 기전분석

Food-dependent exercise-induced anaphylaxis (FDEIA) is a distinct form of food allergy induced by physical exercise. It is typified by the onset of anaphylaxis during exercise, which is preceded by the ingestion of causal food allergens. Diagnosis of FDEIA is heavily dependent on clinical history. To describe the physiopathological mechanism, etiologic factors, and clinical manifestations, we evaluated the spleen index, proliferation assay of lymphocyte, ROS, ASAS, and cytokines levels in sensitized and exercise-trained mice. One-hundred mice were bred in the animal lab at D and P university under controlled conditions [22±2℃, RH 45-55%, and a 12-hour photoperiod]. Animals are 7-weeks-old at the time of study and were fed a standard commercial chow diet from 09:00 to 15:00 over the 8-week study period. The mice were allowed access to distilled deionized water ad libitum. Daily food intake and weekly body gains were routinely recorded throughout the experimental period using computing scale (CAS). Mice were divided into the control group (S; control sensitized, n=25), 30 min swim training group (S30, N=25), 50 min swim training group (S50, N=25), and 80 min swim training group (S80, N=25). The results were as follows: Spleen index showed the highest level in the S80 group compared to other groups; this level was exercise-dependent. In proliferation assay of Med and OVA, the S80 group showed the highest level compared to the other groups; this level also was exercise intensity-dependent. Peritoneal ROS and IL-4 showed a statistically significant difference compared to S; however, there was no significant differences in ROS among S30, 50, and 80. From the results, we concluded that FDEIA is correlated with exercise intensity based on the levels of peritoneal ROS and cytokine profiles.

환경, 음식 및 운동 알레르기 반응에 대한 고찰

규칙적인 운동이 면역력 증가에 도움을 주는 것이 일반적인 사실이지만 차고 건조한 환경에서의 격렬한 운동은 호흡기 질환의 일종인 운동 유발성 천식과 운동 유발성 알레르기 질환을 야기하고, 상기도 감염 등을 유발하기도 한다. 이는 수행되는 운동의 종류나 방법 등에 따라서 다르게 나타나며 운동 수행의 경험과 운동 환경 등에 따라서 상이하게 나타난다. 따라서 운동하는 환경이 야외에서 이루어지며 오존이나 먼지 등을 많이 접하면서 수행되는 운동과 동계 스포츠인 스키, 스노우보드, 스케이트 및 아이스하키와 같은 운동 수행으로 운동 시 폐가 차갑고 건조한 공기에 장시간 노출됨에 따라 운동 유발성 천식과 운동유발성 알레르기 반응이 초래된다. 이러한 반응은 음식 알레르기와도 함께 나타나는데, 음식 알레르기가 있는 사람은 운동 시 더욱 알레르기 반응이 증가하게 되고, 음식 알레르기가 나타나지 않은 사람도 특정 음식 섭취 후 격렬한 운동 시 운동 유발성 알레르기가 나타나기도 한다. 이는 일반적으로 소화된 음식물이 장으로 지나갈 때, 혈액의 IgA가 덜 소화된 단백질을 혈액으로 들어오는 것을 방어해 주지만, 결렬한 운동이나 스트레스 상황에서는 IgA가 감소하게 되고, 이러한 상황에서 음식 유발성 알레르기 질환이 나타나게 되는데, 운동 시 이러한 반응이 더욱 심화되며 운동 유발성 알레르기 아나플락시스로 나타나기도 한다. 운동 유발성 알레르기 질환은 운동의 방법, 종류 및 수행되는 운동시간 등에 따라 깊은 관련이 있으며, 임상적인 징후로는 심한 기침, 가슴의 답답함, 호흡 곤란, 쌕쌕거림의 현상, 피부두드러기 및 혈관부종, 심할 경우 혈관파괴 등의 현상이 나타나고, 돌연사의 원인이 되기도 한다. 격렬한 운동은 과 호흡을 유발시키고, 이로 인해 폐의 비만세포가 증가하게 되며, 증가된 비만세포에서 나오는 히스타민이 알레르기 반응을 유발한다. 운동 유발성 두드러기나 아나필락시스 진단에 있어 가장 중요한 사항은 가족력과 병력에 대한 사항이며, 이외에도 메타콜린 피부 반응검사 등이 있다. 치료는 일상생활에서 활동의 수준과 범위를 수정하는 하는 것이 핵심이며, 이를 위해서는 전문가를 통한 환자 교육이 매우 중요하며, 식후에는 시간을 두고 운동해야 한다. 그리고 운동전 알레르기를 유발하는 음식물의 섭취를 제한해야 한다. 본 연구자는 운동 알레르기와 관련된 인자를 크게 운동 시의 환경과 음식물로 구분하고, 여러 문헌을 고찰하여, 운동 시 일어날 수 있는 알레르기 반응을 미연에 방지하고, 운동을 수행하는 엘리트 운동선수 및 동호인, 운동을 지도하는 지도자, 스포츠 산업에 종사하는 사람들에게 기초자료를 제공하고자 한다. Exercise-induced anaphylaxis (EIA) is a physical allergy, sometimes severe, triggered by exertion following specific food intake. It was defined for the first time in 1980. EIA is associated with different kinds of exercise. The clinical manifestations progress from itching, erythema and urticaria to some combination of cutaneous angioedema and vascular collapse. Mast cell participation in the pathogenesis of this syndrome has been proved by the findings of an elevated serum histamine level during exhaustive exercise. As predisposing factors of EIA, a specific or even nonspecific sensitivity to food has been reported. Food-dependent exercise-induced anaphylaxis (FDEIA) is a distinct form of food allergy induced by physical exercise. It is typified by the onset of anaphylaxis during exercise which was preceded by the ingestion of the causal food allergens. The diagnosis of FDEIA is heavily dependent on clinical history. Allergy tests may need to be performed using a broad panel of food and food additives. As with food allergies, FDEIA diagnosis is based on interview, biological test and skin test. Prophylaxis aims to prevent a recurrence; the patient should be given an emergency kit to deal with any recurrent episodes. After the food allergen has been identified, it should be avoided for at least 4 to 5 hours before any exercise. Two cases of EIA are presented (EIA to circumstances; FDEIA) in this paper, The diagnosis, pathophysiology and therapy of FDEIA are also reviewed.

Food-dependent Exercise-induced Anaphylaxis – A Review of 5 Cases

Food-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon and under-recognised syndrome that clinicians may not consider in a patient presenting with anaphylaxis. We describe here 5 patients aged 9 to 20 years old who presented at a local tertiary hospital over a 2-year period from August 2006 to July 2008. All presented with urticaria, 4 were hypotensive, 2 had angioedema and another 2 had dyspnoea. The symptoms occurred between 15 and 150 minutes (mean, 81) after exercising and consuming various food. All had consumed shellfish. All patients were admitted with the diagnosis of anaphylaxis of undefined aetiology. Diagnosis of FDEIA was only reached upon referral to an allergist. Patients were treated with standard medicines for anaphylaxis including adrenaline, antihistamines, steroids and fluid flushes. Symptoms resolved in 2 to 3 days with no further episodes. At discharge, patients were prescribed epinephrine auto-injectors and given written anaphylaxis management plans. More public awareness and strategies to ensure accurate diagnosis and management of this condition are necessary.

Food related, exercise induced anaphylaxis.

Four children under 12 years of age with food dependent, exercise induced anaphylaxis (EIAn) were investigated. These children and five controls performed exercise challenges when fasting and one hour after a meal without food suspected to predispose to the reaction. Patients then performed exercise tests after intake of each suspected food. Three out of 15 food-exercise combination challenges were positive, but no reactions were provoked after exercise without prior intake of suspected foods. Patients underwent skin prick tests to foods and serum total and specific IgE antibodies were measured. Skin prick test results were positive and RAST results were positive in two of three instances. In case 3, food-exercise combination challenges did not provoke any clinical reaction. The diagnosis of food dependent EIAn should be considered in young children with EIAn of unknown origin.