Exercise-induced Anaphylaxis Research Articles

Endurance exercise after orange ingestion anaphylaxis

Endurance exercise after orange ingestion cause anaphylaxis which is food-dependent exercise-induced anaphylaxis (FDEIA) which is a form of exercise-induced anaphylaxis. In this article, an individual develops symptoms such as flushing, itching, urticaria, angioedema, and wheezing after eating a food allergen and proceeds to exercise. Neither the food alone nor exercise alone is sufficient to induce a reaction. This case report describes a 36-year-old asthmatic male athlete who experienced nausea, vomiting, flushing, urticaria, and facial swelling while exercising in a gymnasium after eating oranges. Neither oranges alone nor exercise alone induced the reaction. Total avoidance of suspected food allergens would be ideal. Persons with FDEIA should keep at hand an emergency kit with antihistamines, injectable rapid action corticoids, and adrenaline.

血漿ヒスタミン測定が診断に有用であった食物依存性運動誘発アナフィラキシーの1例

症例は15歳男児. ラーメン1杯を摂取後に行ったランニング中に顔面の発赤・腫脹, 呼吸困難などのアナフィラキシー症状を認めた. それまで小麦製品摂取による即時型の誘発症状はなく, 小麦による食物依存性運動誘発アナフィラキシー (FDEIA) を疑い誘発試験を実施した. 誘発試験において症状は認めなかったが, 小麦負荷と運動負荷, アスピリン負荷と小麦負荷, アスピリン負荷と小麦負荷と運動負荷のいずれの組み合わせにおいても, 血漿ヒスタミン濃度が誘発試験前値の200%, 190%, 248%と上昇を認めたため, 小麦によるFDEIAと診断した. エピペン®を所持してもらい, 小麦製品摂取後2時間以内の運動制限と解熱鎮痛薬使用中の小麦製品摂取の制限ならびに運動制限について指導した. 血漿ヒスタミン濃度の上昇を診断に用いることで, 誘発症状がないために偽陰性と判断されることの危険を回避しうることは, 臨床上極めて有用である.

Analysis of clinical characteristics of food-dependent exercise-induced anaphylaxis at a single tertiary hospital

Purpose: Food-dependent exercise-induced anaphylaxis (FDEIA) is a rare subtype of food allergy in which both sensitization to food allergen and exercise as a trigger contribute to its development. However, its pathogenesis is still under investigation. This study compared clinical features, the causative foods, and the degree of sensitization to food between FDEIA and food anaphylaxis to characterize FDEIA more clearly. Methods: We retrospectively reviewed the medical records of patients who were diagnosed with FDEIA (n=89) or food anaphylaxis (n=115) between 2003 and 2015 at Seoul National University Hospital. Results: Subjects with FDEIA more frequently had urticaria than those with food anaphylaxis (88.8% vs. 76.5%, P=0.024). Whereas patients with FDEIA had less laryngeal edema than those with food anaphylaxis (12.4% vs. 30.4%, P=0.02). Wheat (67.4%) was the most common causative food allergen in FDEIA, whereas seafood (40.9%) was the most common culprit food allergen in food ana phylaxis. Also, subjects with FDEIA showed a lower atopic index score than those with food anaphylaxis (0.55±1.07 vs. 1.21±1.82, P=0.006). Conclusion: There were significant differences in clinical manifestation, causative food allergens and the degree of sensitization to food between FDEIA and food anaphylaxis. (Allergy Asthma Respir Dis 2016:4:436-441)

A cautionary tale for the physician: case report and review of food-dependent exercise-induced anaphylaxis

A cautionary tale for the physician: case report and review of food-dependent exercise-induced anaphylaxis

Wheat‐dependent exercise‐induced anaphylaxis

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare, but potentially severe food allergy exclusively occurring when wheat ingestion is accompanied by augmenting cofactors. It is clinically characterized by anaphylactic reactions ranging from urticaria and angioedema to dyspnoea, hypotension, collapse, and shock. WDEIA usually develops after ingestion of wheat products followed by physical exercise. Other cofactors are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, alcohol, and infections. The precise mechanisms of WDEIA remain unclear; exercise and other cofactors might increase gastrointestinal allergen permeability and osmolality, redistribute blood flow, or lower the threshold for IgE-mediated mast cell degranulation. Among wheat proteins, ω5-gliadin and high-molecular-weight glutenin subunits have been reported to be the major allergens. In some patients, WDEIA has been discussed to be caused by epicutaneous sensitization with hydrolysed wheat gluten included in cosmetics. Diagnosis is made based on the patient's history in combination with allergy skin testing, determination of wheat-specific IgE serum antibodies, basophil activation test, histamine release test, and/or exercise challenge test. Acute treatment includes application of adrenaline or antihistamines. The most reliable prophylaxis of WDEIA is a gluten-free diet. In less severe cases, a strict limitation of wheat ingestion before exercise and avoidance of other cofactors may be sufficient.

Wheat protein recognition pattern in tolerant and allergic children.

Wheat is one of the most common food allergens in early childhood. In contrast to other food allergies, wheat-specific IgE correlates badly with clinical symptoms and relevant components have been identified mostly for wheat-depended exercise-induced anaphylaxis. Moreover, a high percentage of patients present with immediate type symptoms but wheat-specific IgE cannot be detected with commercial available systems. We addressed the question whether the IgE recognition pattern between wheat allergic (WA) and clinically tolerant (WT) children differs in order to identify individual proteins useful for component-resolved diagnostics. Sera of 106 children with suspected wheat allergy, of whom 44 children had clinical relevant wheat allergy and 62 were tolerant upon oral food challenge, were analyzed for wheat-specific IgE using the ImmunoCap system as well as immunoblots against water and salt soluble, and water-insoluble protein fractions. 40 randomly selected sera were analyzed for specific IgE to ω5-gliadin. Sixty-three percent of the WT and 86% of the WA children were sensitized to wheat with >0.35 kUA /l in ImmunoCAP analysis. We could confirm the role of α-, ß-, γ-, and ω-gliadins, and LMW glutenin subunits as major allergens and found also IgE binding to a broad spectrum of water- and salt-soluble protein bands. It is of great importance that wheat allergic and tolerant patients showed IgE binding to the same protein bands. WT and WA did not significantly differ in levels of ω5-gliadin-specific IgE. Children with challenge proven clinical relevant food allergy and tolerant ones had a similar spectrum of IgE binding to the same protein bands. These findings imply that component-resolved diagnostics might not be helpful in the diagnostic work-up of wheat allergy.

Assessment of the Allergenic Potential of Transgenic Wheat (Triticum aestivum) with Reduced Levels of ω5-Gliadins, the Major Sensitizing Allergen in Wheat-Dependent Exercise-Induced Anaphylaxis.

The ω5-gliadins are the major sensitizing allergens in wheat-dependent exercise-induced anaphylaxis (WDEIA). In this study, two-dimensional immunoblot analysis was used to assess the allergenic potential of two transgenic wheat lines in which ω5-gliadin genes were silenced by RNA interference. Sera from 7 of 11 WDEIA patients showed greatly reduced levels of immunoglobulin E (IgE) reactivity to ω5-gliadins in both transgenic lines. However, these sera also showed low levels of reactivity to other gluten proteins. Sera from three patients showed the greatest reactivity to proteins other than ω5-gliadins, either high-molecular-weight glutenin subunits (HMW-GSs), α-gliadins, or non-gluten proteins. The complexity of immunological responses among these patients suggests that flour from the transgenic lines would not be suitable for individuals already diagnosed with WDEIA. However, the introduction of wheat lacking ω5-gliadins could reduce the number of people sensitized to these proteins and thereby decrease the overall incidence of this serious food allergy.

Study on the Immunoreactivity of Triticum monococcum (Einkorn) Wheat in Patients with Wheat-Dependent Exercise-Induced Anaphylaxis for the Production of Hypoallergenic Foods.

Wheat [Triticum aestivum (T.a.)] ingestion can cause a specific allergic reaction, which is called wheat-dependent exercise-induced anaphylaxis (WDEIA). The major allergen involved is ω-5 gliadin, a gluten protein coded by genes located on the B genome. Our aim was to study the immunoreactivity of proteins in Triticum monococcum (einkorn, T.m.), a diploid ancestral wheat lacking B chromosomes, for possible use in the production of hypoallergenic foods. A total of 14 patients with a clear history of WDEIA and specific immunoglobulin E (IgE) to ω-5 gliadin were enrolled. Skin prick test (SPT) with a commercial wheat extract and an in-house T.a. gluten diagnostic solution tested positive for 43 and 100% of the cases, respectively. No reactivity in patients tested with solutions prepared from four T.m. accessions was observed. The immunoblotting of T.m. gluten proteins performed with the sera of patients showed different IgE-binding profiles with respect to T.a., confirming the absence of ω-5 gliadin. A general lower immunoreactivity of T.m. gluten proteins with scarce cross-reactivity to ω-5 gliadin epitopes was assessed by an enzyme-linked immunosorbent assay (ELISA). Given the absence of reactivity by SPT and the limited cross-reactivity with ω-5 gliadin, T.m. might represent a potential candidate in the production of hypoallergenic bakery products for patients sensitized to ω-5 gliadin. Further analyses need to be carried out regarding its safety.

SIX CASES OF WHEAT-DEPENDENT EXERCISE-INDUCED ANAPHYLAXIS IN CHILDREN

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is often reported in adults for whom the specific IgE to ω-5 gliadin can be a useful diagnostic test. However, few cases of WDEIA in children have been reported. We herein report six cases (aged 7-16 years) of children with WDEIA, who had no clinical history of immediate-type wheat allergy but who were diagnosed by a wheat ingestion + exercise provocation test. The specific IgE to wheat ranged <0.35-3.49 (median 1.64) UA/ml. Skin prick tests using wheat extract were performed on 3 patients who showed either a negative or low specific IgE titer to wheat, and all of them resulted in negative findings. The specific IgE to ω-5 gliadin was below the detection limit in all cases. Aspirin-supplemented provocation tests were performed to 4 cases who had negative results in the wheat + exercise test. All of these resulted in a positive reaction, and two of them provoked the occurrence of anaphylactic shock, which was relieved by the intramuscular injection of adrenaline. WDEIA in children cannot be ruled out by serological tests alone. On the other hand, severe symptoms might be provoked by the provocation test. Therefore, a safe procedure is warranted for the diagnosis of WDEIA in children.

Gluten and wheat sensitivities – An overview

Wheat products are important staple foods worldwide. However, a small portion of the population has to avoid wheat-containing foods because of harmful immune responses. Countless studies have demonstrated that the storage (gluten) proteins of wheat are major causative agents for wheat-dependent immune-mediated disorders. The unique structural features of gluten proteins are long repetitive amino acid sequences rich in glutamine and proline. These sequence sections are involved in most wheat sensitivities. Corresponding homologous sequence sections of rye and barley proteins may also be harmful, but relevant studies are rare. Wheat sensitivities can be classified into three main forms: autoimmunogenic sensitivities including coeliac disease, dermatitis herpetiformis, and gluten ataxia; allergic sensitivities including immediate wheat allergy, wheat-dependent exercise-induced anaphylaxis, respiratory allergy, and contact urticaria; and non-coeliac gluten sensitivity. The presented overview summarizes our current knowledge of gluten protein structures related to wheat sensitivities and the epidemiological, clinical, and pathogenic differences between these immune-mediated disorders.

Pathophysiological mechanisms of exercise-induced anaphylaxis: an EAACI position statement.

This document is the result of a consensus on the mechanisms of exercise-induced anaphylaxis (EIAn), an unpredictable and potentially fatal syndrome. A multidisciplinary panel of experts including exercise physiologists, allergists, lung physicians, paediatricians and a biostatistician reached the given consensus. Exercise-induced anaphylaxis (EIAn) describes a rare and potentially fatal syndrome in which anaphylaxis occurs in conjunction with exercise. The pathophysiological mechanisms underlying EIAn have not yet been elucidated although a number of hypotheses have been proposed. This review evaluates the validity of each of the popular theories in relation to exercise physiology and immunology. On the basis of this evidence, it is concluded that proposed mechanisms lack validity, and it is recommended that a global research network is developed with a common approach to the diagnosis and treatment of EIAn in order to gain sufficient power for scientific evaluation.

Eighteen cases of wheat allergy and wheat‐dependent exercise‐induced urticaria/anaphylaxis sensitized by hydrolyzed wheat protein in soap

Glupearl 19S, an acid-hydrolyzed wheat protein (HWP), is used widely in Japan as a moisturizing ingredient in facial soaps. Since 2010, there has been an increasing number of reports of contact urticaria and wheat allergy resulting from the use of products containing this substance. Sixty-one patients who had used HWP-containing facial soap visited our hospital. Thirty-five of these experienced urticaria or anaphylaxis after consuming wheat-containing food. Eighteen of the 35 patients tested positive to 0.01% Glupearl 19S solution. Wheat-specific IgE and serum gluten-specific IgE were higher in the patients with HWP allergy than in non-HWP allergy patients. Among the patients who tested positive to Glupearl 19S on the skin prick test, nine experienced HWP-wheat-dependent exercise-induced anaphylaxis, and four experienced food-dependent anaphylaxis. Moreover, four of these patients not only experienced food-dependent anaphylaxis but also a worsening of the symptoms during exercise. The clinical symptomology was so variable that the patients were classified into six groups. We found that patients with HWP allergy tended to manifest symptoms of both HWP-wheat-dependent exercise-induced anaphylaxis and contact urticaria. The etiology of hydrolyzed wheat protein allergy is unknown. Patients with a history of these symptoms need to be informed about the risk of consuming wheat-containing foods and the importance of excluding such items from their diet.

Cholinergic urticaria in a jogger: ruling out exercise-induced anaphylaxis.

Cholinergic urticaria is a systemic response to a rise in core temperature that can be brought on by exercise, as in this case of a 24-year-old jogger. Many cases, however, are mild. The exact pathophysiology for the release of histamines is unknown, but the resulting rash can be distressing for patients. The challenge for physicians is to differentiate exercise-induced urticaria from exercise-induced anaphylaxis, a potentially life-threatening condition. Effective management includes patient education, antihistamine use, if needed, and avoidance of precipitating triggers, such as strenuous exercise or hot showers.

Identifying exercise allergies: exercise-induced anaphylaxis and cholinergic urticaria.

Exercise-related allergies vary from the benign rash of cholinergic urticaria to life-threatening exercise-induced anaphylaxis. Rapid diagnosis is essential, but it can be difficult to tell the two conditions apart. The size of the wheals and the patient history provide the best clues. Giving epinephrine and taking steps to protect the patient's airway, breathing, and circulation are standard treatment for exercise-induced anaphylaxis. Effective management for less severe cases involves exercising with a partner, keeping self-injectable epinephrine on hand, and avoiding exercise before and after meals. Prophylactic antihistamines are more effective for cholinergic urticaria than for exercise-induced anaphylaxis.

Cloning and characterization of novel fast ω-gliadin genes in Triticum monococcum.

Fast ω-gliadin is the major allergen to wheat-dependent exercise-induced anaphylaxis (WDEIA). It is generally accepted that the proteins were expressed inGli-B1 loci located on the short arm of chromosome 1B in wheat. The knowledge of the orthologous genes in A and D genomes is still limited. In this study, the novel fastω-gliadin genes were cloned from genome A of diploid wheat Triticum monococcum. The deduced amino acid sequences of N-terminal domain showed that they referred to TRQ-type ω-gliadins. This type of ωgliadins have been identified in genome A by using mass spectroscopy and amino acid sequencing in previous studies (DuPont et al. 2004), but their coding sequences were lacking. Further analysis of IgE-binding epitopes suggested that the TRQ-typeω-gliadins have potential to trigger WDEIA. Wheat is one of the most important sources of food in the human diet. In the kernels of wheat, gliadins are the main components of the gluten. Traditionally, gliadins are further classified into α-gliadins, γ-gliadins and ω-gliadins on the basis of their mobility in electrophoresis at low pH (Wan et al. 2014). The ω-gliadins are minor components among wheat prolamins and they have not been studied well due to difficulties in cloning their genes caused by highly repetitive sequences (Anderson et al. 2009). In common wheat, most of the ω-gliadins were encoded by the Gli-A1, Gli-B1 and Gli-D1 on the short arm of chromosomes 1A, 1B and 1D, respectively (Pogna et al. 1990; Shewry et al. 1995; DuPont et al. 2000, 2004). Theω-gliadins have been categorized into ω1,ω2 andω5 types (DuPont et al. 2004). Theω5-gliadin, also referred as fastω-gliadin, are encoded byGli-B1 and the proteins can be distinguished by the amino acid sequences at the N-terminal domain, which are Ser-Arg-Leu (SRL) in ω5-gliadin, Ala-Arg-Gln (ARQ) or Lys-Glu-Leu (KEL)

Exercise-induced anaphylaxis after consumption of red meat in a patient with IgE antibodies specific for galactose-alpha-1,3-galactose

In 2009, Commins and Platts-Mills reported a “novel form of delayed anaphylaxis to red meat” related to serum IgE antibodies to the oligosaccharide galactose-alpha 1,3-galactose (alpha-gal) caused by a tick bite from the lone star tick, Amblyomma americanum. It is now recognized that IgE antibody to alpha-gal is common in the southeastern United States and is associated with 2 forms of anaphylaxis: immediate-onset anaphylaxis during first exposure to intravenous cetuximab and delayed-onset anaphylaxis after ingestion of mammalian meat. This information has added a new aspect to the care of patients who might otherwise have been diagnosed with idiopathic anaphylaxis, which can be quite frustrating for patients and clinicians alike. In cases of mammalian meat allergy due to alphagal, we are now able to provide patients with the answer to the frequently asked question, “What can I do to prevent these reactions?” Not only can we provide them with a diagnosis, but in so doing we improve their quality of life and provide them with the knowledge of what to avoid to prevent these potentially life-threatening reactions. Although more cases have been recognized and diagnosed since the initial report of anaphylaxis to mammalian meat due to alpha-gal, there are multiple factors that can prevent or delay diagnosis. As Tripathi et al noted, “the lack of enthusiasm for this syndrome could be easily understood because its features run counter to many established teachings about food allergy and anaphylaxis.” It is taught that food allergy reactions typically begin within 1 to 2 hours of consumption of the offending food and with every ingestion. However, in alpha-galeinduced mammal meat allergy, the reaction is delayed, and in most cases occurs 3 to 6 hours after consuming beef, pork, venison, or lamb. Many patients do not have positive skin prick test results to meat extracts. Therefore, intradermal testing to meat is now being done. Patients also may be unaware of or fail to recall previous tick bites. In addition, patients may not experience reactions with every ingestion of mammalian meat, which may be due to the type, processing, dose, and/or preparation of the mammalian meat product. It should be noted that the severity of reactions may worsen over time with continued tick bites. The most commonly reported symptom was itching. To add to the growing body of knowledge regarding mammalian meat allergy due to alpha-gal, we are presenting a novel case of exercise-induced anaphylaxis (EIA) after ingestion of red meat in a patient with IgE antibodies to alpha-gal. In this case, the reactions also occurred more rapidly than typical alphagal reactions, happening in 1 to 1/2 hours instead of 3 to 6 hours.

Occupational allergic multiorgan disease induced by wheat flour

Bakers are repeatedly exposed to wheat flour (WF) and may develop sensitization and occupational rhinoconjunctivitis and/or asthma to WF allergens.1 Several wheat proteins have been identified as causative allergens of occupational respiratory allergy in bakery workers.1 Testing of IgE reactivity in patients with different clinical profiles of wheat allergy (food allergy, wheat-dependent exercise-induced anaphylaxis, and baker's asthma) to salt-soluble and salt-insoluble protein fractions from WF revealed a high degree of heterogeneity in the recognized allergens. However, mainly salt-soluble proteins (albumins, globulins) seem to be associated with baker's asthma, and prolamins (gliadins, glutenins) with wheat-dependent exercise-induced anaphylaxis, whereas both protein fractions reacted to IgE from food-allergic patients.1 Notwithstanding, gliadins have also been incriminated as causative allergens in baker's asthma.2 We report on a 31-year-old woman who had been exposed to WF practically since birth because her family owned a bakery housed in the same home where they lived. She moved from this house when she was 25 years, but she continued working every day in the family bakery. In the last 8 years she had suffered from work-related nasal and ocular symptoms such as itching, watery eyes, sneezing, nasal stuffiness, and rhinorrhea. These symptoms markedly improved when away from work and worsened at work. In the last 5 years, she had also experienced dysphagia with frequent choking, especially when ingesting meats or cephalopods, which had partially improved with omeprazole therapy. Two years before referral to our clinic, she began to have dry cough and breathlessness, which she also attributed to her work environment. Upper and lower respiratory tract symptoms increased when sifting the WF and making the dough. The patient did not experience gastrointestinal symptoms with ingestion of cereal products. Skin prick test results were positive to grass (mean wheal, 6 mm), cypress (5 mm) and Russian thistle pollen (4 mm), WF (4 mm), and peach lipid transfer protein (6 mm) and were negative to rice flour, corn flour, profilin, mites, molds, and animal dander. Skin prick test with a homemade WF extract (10% wt/vol) was strongly positive (15 mm). Serologic tests yielded the following results: eosinophil cationic protein, 47 ?g/L; total serum IgE, 74 kU/L; specific IgE (ImmunoCAP; ThermoFisher, Uppsala, Sweden) to WF, 7.4 kU/L; barley flour, 1.24 kU/L; and corn, gluten, alpha-amylase, peach, and apple, less than 0.35 kU/L. Specific IgE binding to microarrayed purified WF allergens (WDAI-0.19, WDAI-0.53, WTAI-CM1, WTAI-CM2, WTAI-CM3, WTAI-CM16, WTAI-CM17, Tri a 14, profilin, ?-5-gliadin, Tri a Bd 36 and Tri a TLP, and gliadin and glutamine fractions) was assessed as described elsewhere.3 The patient's serum specifically recognized ?-5-gliadin and the gliadin fraction, and no IgE reactivity was observed to other wheat allergens. Spirometry revealed a forced vital capacity of 3.88 L (88%), an FEV1 of 3.04 L (87%), and FEV1/forced vital capacity of 83%. A methacholine inhalation test was performed following an abbreviated protocol,4 and the results were expressed as PD20 in cumulative dose (mg) of methacholine. Methacholine inhalation challenge test result was positive (0.24 mg cumulative dose) when she was working, and after a 3-month period away from work and with no visits to the bakery house, it gave a negative result. A chest x-ray was normal. Specific inhalation challenge test was carried out in the hospital laboratory by tipping WF from one tray to another for 15 minutes. Spirometry was performed at baseline and at 2, 5, 10, 15, 20, 30, 45, and 60 minutes after the challenge with WF. Peak expiratory flow was measured at baseline and then hourly over 24 hours (respecting sleeping time). A 12% fall in FEV1 was observed at 20 minutes and a 26% drop in peak expiratory flow at 9 hours after exposure to WF,

A dangerous exercise

Exercise induced anaphylaxis and its subtype the Food-dependent exercise-induced anaphylaxis are uncommon and therefore under-diagnosed forms of physical allergy. Triggers include various degrees of exercise in combination with ingestion of specific food products. Treatment remains identical to that of Immunoglobulin E- mediated allergic reactions. The presentation is commonly under diagnosed and this case should raise the awareness of the attending Allergist/Physician. A 30 year old female was seen in the Allergy Clinic upon request of her General Practitioner. She reported an episode where after dinner she went into a local park to exercise. Shortly thereafter she collapsed with rash, lip swelling and breathing difficulties. Upon admission to hospital she was found to be hypotensive and required fluid resuscitation, systemic corticosteroids and adrenaline. She made a full and eventful recovery. Based on the clinical story and the subsequent specific allergy markers her presentation was attributed to food- induced exercise-induced anaphylaxis (FD-EIA).

Anaphylaxis to African finger millet with exercise as a possible co‐factor

The following case report describes the rare occurrence of anaphylaxis to African finger millet with exercise as a possible co-factor. An young adult with no pets nor background history of atopic disease, consumed for the first time a Sri Lankan pancake made from “kurakkan flour”, coconut and sugar. The patient then undertook a strenuous walk, following which he developed anaphylaxis requiring emergency treatment with Adrenaline, nebulised Salbutamol, corticosteroids and antihistamines. On subsequent review, the patient reported no further reactions and had reintroduced coconut into their diet. They had not ingested any further “kurakkan flour”, but continued with a regular and intensive exercise regimen with no clinical reactions. Skin prick tests demonstrated sensitisation to dustmite and grass pollens; common food allergens tested were all negative. A preparation of the implicated flour mixed with saline into a thin paste was used for skin testing and the patient demonstrated a 6 x 6mm positive reaction. Three healthy volunteers tested negative to the same preparation. Kurakkan flour is prepared from African finger millet and is commonly used in Sri Lankan cooking. Anaphylaxis to millet was first described in 1981,[1] however a limited number of case reports suggests this is a rare reaction. More recent publications describe hypersensitivity in bird keepers with sensitisation occurring via inhalational exposure to millet in birdseed.[2] Millet sensitisation has been demonstrated in bird keepers both with and without a history of clinical reactivity.[3] Cross reactivity between rice and millet species can occur secondary to sensitisation to a 16kD allergen in rice grains.[4] Notably, the major prolamin in millet is panicin, which has not been shown to demonstrate cross-reactivity with omega-5-gliadin, the allergenic wheat prolamin implicated in wheat-dependent exercise-induced anaphylaxis. Although cases of millet anaphylaxis have been described with no prior history of sensitisation,[5,6] this is the first report describing millet anaphylaxis with exercise as a possible co-factor. Whilst millet is not a commonly used food, the growing popularity of gluten-free and “natural” diets may result in an increasing frequency of clinical reactivity in Western populations.

Experimental assessments of the cross‐reactivity of IgE from patients sensitised with acid‐hydrolysed wheat protein in a cosmetic soap

Hydrolysed wheat protein (HWP), which has high emulsifying property and water retentivity, is added to various foods and cosmetics to improve their texture. Recently, several studies showed that a specific HWP formula could induce IgE-mediated hypersensitivity by skin contact and/or food ingestion. In Japan, a number of HWP-caused systemic wheat allergy cases were reported, including wheat-dependent exercise-induced anaphylaxis after sensitisation to acid-hydrolysed gluten additive [Glupearl 19S® (Glp19S)] in a cosmetic soap. These allergic manifestations are believed to result from deamidated peptides in high-molecular weight fractions of Glp19S. However, relationships between the properties of HWP and its allergenicity remain unknown. Here, we experimentally assessed the cross-reactivity of IgE from Glp19S-sensitised patients' sera by examining the IgE-binding capacity to various HWPs generated under different conditions and the ability to elicit mast cell activation. We prepared three different HWP types by acidic hydrolysis (0.1M HCl treatment at 100°C), alkaline hydrolysis (1M NaOH treatment at 100°C) and enzymatic hydrolysis (Neutrase® digestion at 50°C) for 0.5, 1, 3, 6, 9, 12 and 24 h, respectively. We examined the capacity of IgE binding to various acid-HWPs and native gluten using Western blotting. After 0.5-1 h of acid hydrolysis, IgE immunoblotting with a patient's serum showed smears at around 40-70-kDa proteins. However, after 3 h of acid hydrolysis, IgE binding to 40-70-kDa proteins time-dependently decreased. Regarding mast cell activation by acid-HWPs, a 0.5-h hydrolysis sample showed dramatically increased mast cell activation, whereas native gluten had little effect on it. Even after prolonged hydrolysis, acid-HWPs still retained the ability to activate mast cells, with only slightly decreased activity levels. The alkaline and enzymatic hydrolysis samples are currently under investigation to assess cross-reactivity. In conclusion, we showed that allergenic HWP had specific molecular properties given by hydrolysis. These results showed that it may be possible to reduce the risk of HWP-caused allergy by the regulation of hydrolysis procedures.