Wheat-dependent Exercise-induced Anaphylaxis Research Articles

Evaluation of the allergenicity of ω5-gliadin-deficient Hokushin wheat (1BS-18) in a wheat allergy rat model

We previously developed Hokushin wheat line as a hypoallergenic wheat lacking ω5-gliadin (1BS-18), a major allergen for wheat-dependent exercise-induced anaphylaxis. However, the allergenicity of 1BS-18 has not been understood completely. In this study, we evaluated the allergenicity of 1BS-18 such as anaphylactic elicitation ability and sensitization ability using rats sensitized with ω5-gliadin or glutens prepared from Hokushin (Hokushin gluten) or 1BS-18 (1BS-18 gluten). Rats were sensitized by intraperitoneal administration of ω5-gliadin, Hokushin gluten or 1BS-18 gluten. Immunoglobulin E-mediated systemic anaphylaxis was evaluated by measuring changes in rectal temperature for 30 min after intravenous challenge with ω5-gliadin or the test glutens in unsensitized rats or rats sensitized with ω5-gliadin or the test glutens. In ω5-gliadin-sensitized rats, intravenous challenge with ω5-gliadin or Hokushin gluten significantly decreased the rectal temperature at 30 min after challenge while challenge with 1BS-18 gluten did not reduce the rectal temperature. Furthermore, intravenous challenge with ω5-gliadin significantly decreased the rectal temperature in rats sensitized with Hokushin gluten or 1BS-18 gluten. However, the reduced degree observed in 1BS-18 gluten-sensitized rats was smaller than that in Hokushin gluten-sensitized rats. In conclusion, 1BS-18 elicited no allergic reaction in ω5-gliadin-sensitized rats and had less sensitization ability for ω5-gliadin than that of Hokushin wheat.

Food-Dependent Exercise Anaphilaxy: A Systematic Review of Literature

Over and over again food-induced exercise-induced anaphylaxis is underdiagnosed by the physician and is reported to be an idiopathic anaphylaxis. In this context, the patient does not receive the proper guidelines for the correct management of his disease. Therefore, you will not know how to act, either to avoid it or to intervene in a possible crisis, so you will be potentially subject to life-threatening situations. Thus the research question was thus outlined: “How should the patient with food-dependent exercise-induced anaphylaxis (AIEDA) act in the face of a likely crisis, particularly in reducing the number of fatal events?” A literature review was performed. on the following bases: Online Medical Literature Search and Analysis System (MEDLINE), Scientific Electronic Library Online (SCIELO). The following controlled descriptors were selected for the location of the studies: “Wheat-Dependent Exercise-Induced Anaphylaxis”, “Impending Anaphylactic Crisis”, “Patients Exposed to Imminent Anaphylactic Crisis” (patients exposed to impending anaphylactic crisis). ). Exercise-induced anaphylaxis (EIA) is believed to be associated with 5-15% of all anaphylaxis cases. AIEDA prevalence data are limited and not reported accurately. Most reported cases have been related to wheat. Reported prevalence ranged from 0.001% to 0.017% worldwide for all foods. In most patients, when there is a mediated IgE reaction, exercise decreases the threshold for mast cell degranulation, giving rise to symptoms even when isolated ingestion is tolerated. Severe food allergy sometimes develops during exercise in association with a specific food (up to four hours after ingestion), characterizing food-dependent exercise-induced anaphylaxis. Proper professional diagnosis and management will help to avoid unnecessary limitations on the patient's diet and exercise. In any situation of anaphylaxis, it is never an exaggeration to stress the importance of educating patients to know how and when to use the self-injecting adrenaline kit, and to convey the notion of ineffective premedication with antihistamines. even mask prodromal symptoms, preventing patients from predicting more severe reactions. Keywords: Wheat-Dependent Exercise-Induced Anaphylaxis; Impending anaphylactic crisis; Patients exposed to impending anaphylactic crisis

145 Establishment of wheat peroxidase I-specific IgE test to identify wheat-dependent exercise-induced anaphylaxis developed by sensitization to grass pollen

145 Establishment of wheat peroxidase I-specific IgE test to identify wheat-dependent exercise-induced anaphylaxis developed by sensitization to grass pollen

Wheat‐dependent exercise‐induced anaphylaxis in Chinese people: a clinical research on 33 cases with antigenic analysis of wheat proteins

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a severe allergic condition in which wheat ingestion together followed by physical exercise induces anaphylaxis. For patients with WDEIA, omega-5 gliadin is considered to be one of the major allergens. To analyse the clinical features and allergen spectrum of WDEIA and to investigate the relationship between WDEIA and serum levels of platelet-activating factor (PAF), interleukin (IL)-9 and IL-33. Medical histories and conditions of WDEIA cases were collected and summarized, with allergen tests of wheat proteins measured at the same visit. Of the 33 patients enrolled, 13 also had serum levels of PAF, IL-9 and IL-33 measured. The healthy control (HC) group consisted of 13 healthy individuals, who also underwent both the wheat-protein allergen tests and the inflammatory-mediator tests. All patients experienced severe allergic reaction during exercise after wheat ingestion. Manifestations of WDEIA included facial oedema, generalized urticaria and respiratory symptoms. Unconsciousness was also observed in 21 cases. In the patient group, 57.6% were confirmed as hypersensitive to glyceraldehyde-3-phosphate dehydrogenase (GAPDH), while 54.5% were allergic to omega-5 gliadin. PAF concentration was significantly higher in patients with WDEIA compared with HCs, whereas there was no significant difference in IL-9 or IL-33 between the two groups. WDEIA is a rare type of anaphylaxis. GAPDH and omega-5 gliadin may be the most common allergy-causing wheat proteins for Chinese people. PAF may be associated with the onset and development of WDEIA.

【特集】日本人が見つけた自己抗原・抗原 食物依存性運動誘発アナフィラキシー：グリアジン

【特集】日本人が見つけた自己抗原・抗原 食物依存性運動誘発アナフィラキシー：グリアジン

Idiopathic anaphylaxis.

Idiopathic anaphylaxis (IA) or spontaneous anaphylaxis is a diagnosis of exclusion when no cause can be identified. The exact incidence and prevalence of IA are not known. The clinical manifestations of IA are similar to other known causes of anaphylaxis. A typical attack is usually acute in onset and can worsen over minutes to a few hours. The pathophysiology of IA has not yet been fully elucidated, although an IgE-mediated pathway by hitherto unidentified trigger/s might be the main underlying mechanism. Elevated concentrations of urinary histamine and its metabolite, methylimidazole acetic acid, plasma histamine and serum tryptase have been reported, consistent with mast cell activation. There is some evidence that corticosteroids reduce the frequency and severity of episodes of IA, consistent with a steroid-responsive condition. Important differential diagnoses of IA include galactose alpha-1,3 galactose (a carbohydrate contained in red meat) allergy, pigeon tick bite (Argax reflexus), wheat-dependent exercise-induced anaphylaxis, Anisakis simplex allergy and mast cell disorders. Other differential diagnoses include "allergy-mimics" such as asthma masquerading as anaphylaxis, undifferentiated somatoform disorder, panic attacks, globus hystericus, vocal cord dysfunction, scombroid poisoning, vasoactive amine intolerance, carcinoid syndrome and phaeochromocytoma. Acute treatment of IA is the same as for other forms of anaphylaxis. Long-term management is individualized and dictated by frequency and severity of symptoms and involves treatment with H1 and H2 receptor blockers, leukotriene receptor antagonist and consideration for prolonged reducing courses of oral corticosteroids. Patients should possess an epinephrine autoinjector with an anaphylaxis self-management plan. There are anecdotal reports regarding the use of omalizumab. For reasons that remain unclear, the prognosis of IA is generally favourable with appropriate treatment and patient education. If remission cannot be achieved, the diagnosis should be reconsidered.

English

Wheat ingestion can lead to disorders such as IgE-mediated food allergy and wheat-dependent exercise-induced anaphylaxis (WDEIA), both of which are associated with impaired quality of life and significant morbidity. Allergy to wheat is relatively benign in children, although its natural history in adults is still unknown. Objective: We used placebo-controlled challenge to evaluate the natural history of wheat hypersensitivity in atopic patients with adultonset wheat allergy.We enrolled 13 patients from an initial cohort of adult patients with IgE-mediated wheat allergy (mean age, 40 years). After diagnosis, the patients observed a wheat-free diet and were followed as outpatients for 5 years to evaluate wheat exposure. Wheat-IgEtiters were determined at the end of follow-up, and a second wheat-challenge was performed.Ten out of 13 patients took part in the study. The mean period of wheat avoidance was 4.2 years. Three patients had spontaneously reintroduced wheat before the second evaluation, after a mean (IQR) of 28 (18-36) months, with only mild gastrointestinal discomfort at reintroduction. At the end of follow-up, 9 of the 10 patients were wheat-tolerant. Two patients had a history of WDEIA. We observed a reduction in IgE levels, with median (IQR) IgE falling from 2.77 (0.35-100) kU/L at diagnosis to 0.88 (0.1-20.8) kU/L. The association between IgE and a negative challenge result was not statistically significant.IgE-mediated wheat allergy in adults is benign and represents a temporary break in gastrointestinal tolerance. Future studies may improve our knowledge of wheat allergens, routes of and factors leading to sensitization, and prognostic biomarkers.

Cofactors of wheat-dependent exercise-induced anaphylaxis do not increase highly individual gliadin absorption in healthy volunteers

BackgroundIn wheat-dependent exercise-induced anaphylaxis (WDEIA), cofactors such as exercise, acetylsalicylic acid (ASA), alcohol or unfavorable climatic conditions are required to elicit a reaction to wheat products. The mechanism of action of these cofactors is unknown, but an increase of gliadin absorption has been speculated. Our objectives were to study gliadin absorption with and without cofactors and to correlate plasma gliadin levels with factors influencing protein absorption in healthy volunteers.MethodsTwelve healthy probands (six males, six females; aged 20–56 years) ingested 32 g of gluten without any cofactor or in combination with cofactors aerobic and anaerobic exercise, ASA, alcohol and pantoprazole. Gliadin serum levels were measured up to 120 min afterwards and the intestinal barrier function protein zonulin in stool was collected before and after the procedure; both were measured by ELISA. Stool microbiota profile was obtained by 16S gene sequencing.ResultsWithin 15 min after gluten intake, gliadin concentrations in blood serum increased from baseline in all subjects reaching highly variable peak levels after 15–90 min. Addition of cofactors did not lead to substantially higher gliadin levels, although variability of levels was higher with differences between individuals (p < 0.001) and increased levels at later time points. Zonulin levels in stool were associated neither with addition of cofactors nor with peak gliadin concentrations. There were no differences in gut microbiota between the different interventions, although the composition of microbiota (p < 0.001) and the redundancy discriminant analysis (p < 0.007) differed in probands with low versus high stool zonulin levels.ConclusionThe adsorption of gliadin in the gut in healthy volunteers is less dependent on cofactors than has been hypothesized. Patients with WDEIA may have a predisposition needed for the additional effect of cofactors, e.g., hyperresponsive or damaged intestinal epithelium. Alternatively, other mechanisms, such as cofactor-induced blood flow redistribution, increased activity of tissue transglutaminase, or increases in plasma osmolality and acidosis inducing basophil and mast cell histamine release may play the major role in WDEIA.

Wheat-dependent exercise-induced anaphylaxis with Tri-a-14-sensitization as part of a lipid transfer protein syndrome

Wheat-dependent exercise-induced anaphylaxis with Tri-a-14-sensitization as part of a lipid transfer protein syndrome

Series of 12 cases of wheat-dependent exercise-induced allergy in Aragon, Spain

Background and objectivesThe ω-5 gliadin (ω5G) is considered the main allergen in wheat-dependent exercise-induced anaphylaxis (WDEIA). These patients experience anaphylactic reactions after consuming wheat and performing physical exercise.The aim of our study was to describe the main characteristics of 12 patients with this diagnosis. Material and methodsA descriptive, retrospective study was conducted by reviewing the medical records of 12 patients diagnosed with ω-5G hypersensitivity. ResultsThe patients’ mean age was 37 years, with 50% men and 50% women. Most of the patients had a history of similar unexamined episodes. The latency period varied from immediate to 150min. The most common symptoms were urticaria (83%), bronchospasms (58%), angio-oedema (42%), hypotension (25%) and gastrointestinal symptoms (16%). The most often involved cofactor was physical exercise. The allergy study was conducted with prick tests and total and specific IgE readings. ConclusionsWDEIA is a relatively rare but potentially severe food allergy. Understanding this allergy is therefore important for a correct diagnosis.

Comparisons of in-house wheat skin prick test extracts for the diagnosis of wheat dependent exercise induced anaphylaxis (WDEIA)

Comparisons of in-house wheat skin prick test extracts for the diagnosis of wheat dependent exercise induced anaphylaxis (WDEIA)

Serie de 12 casos de alergia al trigo dependiente de ejercicio físico en Aragón, España

Background and objectivesThe ω-5 gliadin (ω5G) is considered the main allergen in wheat-dependent exercise-induced anaphylaxis (WDEIA). These patients experience anaphylactic reactions after consuming wheat and performing physical exercise.The aim of our study was to describe the main characteristics of 12 patients with this diagnosis. Material and methodsA descriptive, retrospective study was conducted by reviewing the medical records of 12 patients diagnosed with ω-5G hypersensitivity. ResultsThe patients’ mean age was 37 years, with 50% men and 50% women. Most of the patients had a history of similar unexamined episodes. The latency period varied from immediate to 150min. The most common symptoms were urticaria (83%), bronchospasms (58%), angio-oedema (42%), hypotension (25%) and gastrointestinal symptoms (16%). The most often involved cofactor was physical exercise. The allergy study was conducted with prick tests and total and specific IgE readings. ConclusionsWDEIA is a relatively rare but potentially severe food allergy. Understanding this allergy is therefore important for a correct diagnosis.

Wheat allergy in patients with recurrent urticaria

BackgroundClinical observation revealed that most of wheat-induced anaphylaxis (WIA)/wheat-dependent exercise-induced anaphylaxis (WDEIA) patients showed a history of recurrent urticaria. We aim to determine the association between recurrent urticaria and anaphylaxis in wheat allergy. MethodsPopulation-based cohort study involved patients with WIA (n = 193, including WDEIA n = 104), recurrent urticaria (n = 177), non-wheat-related anaphylaxis (n = 584), atopic disease (excluding anaphylaxis, n = 221) and healthy control (n = 95) from 2009 to 2016. Detailed course of urticaria and anaphylaxis were obtained from medical records and following-up questionnaire. Serum IgE specific to wheat, gluten and ω-5 gliadin and skin prick test to wheat were examined. Clinical and laboratory data were statistically analyzed. ResultsIn recurrent urticaria patients, wheat allergy was not rare, and 6.8% (n = 12) was diagnosed as wheat-induced urticaria. Patients with WIA/WDEIA had higher prevalence of recurrent urticaria history than those with non-wheat-related anaphylaxis (164/193, 84.9% vs 85/584, 14.5%), and 70.4% of them (136/193) had recurrent urticaria prior to their first anaphylactic attack. Among patients with WIA/WDEIA and previous urticaria, 46.3% experienced an exacerbation of urticaria. The value of serum specific IgE to ω-5 gliadin was significantly higher in patients with WIA/WDEIA than those with wheat-induced urticaria. ConclusionsWe recommend screening wheat allergy in recurrent urticaria to identify patients who have a potential risk to develop severe reactions earlier.

Towards reducing the immunogenic potential of wheat flour: omega gliadins encoded by the D genome of hexaploid wheat may also harbor epitopes for the serious food allergy WDEIA

BackgroundOmega-5 gliadins are a group of highly repetitive gluten proteins in wheat flour encoded on the 1B chromosome of hexaploid wheat. These proteins are the major sensitizing allergens in a severe form of food allergy called wheat-dependent exercise-induced anaphylaxis (WDEIA). The elimination of omega-5 gliadins from wheat flour through biotechnology or breeding approaches could reduce the immunogenic potential and adverse health effects of the flour.ResultsA mutant line missing low-molecular weight glutenin subunits encoded at the Glu-B3 locus was selected previously from a doubled haploid population generated from two Korean wheat cultivars. Analysis of flour from the mutant line by 2-dimensional gel electrophoresis coupled with tandem mass spectrometry revealed that the omega-5 gliadins and several gamma gliadins encoded by the closely linked Gli-B1 locus were also missing as a result of a deletion of at least 5.8 Mb of chromosome 1B. Two-dimensional immunoblot analysis of flour proteins using sera from WDEIA patients showed reduced IgE reactivity in the mutant relative to the parental lines due to the absence of the major omega-5 gliadins. However, two minor proteins showed strong reactivity to patient sera in both the parental and the mutant lines and also reacted with a monoclonal antibody against omega-5 gliadin. Analysis of the two minor reactive proteins by mass spectrometry revealed that both proteins correspond to omega-5 gliadin genes encoded on chromosome 1D that were thought previously to be pseudogenes.ConclusionsWhile breeding approaches can be used to reduce the levels of the highly immunogenic omega-5 gliadins in wheat flour, these approaches are complicated by the genetic linkage of different classes of gluten protein genes and the finding that omega-5 gliadins may be encoded on more than one chromosome. The work illustrates the importance of detailed knowledge about the genomic regions harboring the major gluten protein genes in individual wheat cultivars for future efforts aimed at reducing the immunogenic potential of wheat flour.

A New Diagnostic Criteria of Wheat-Dependent, Exercise-Induced Anaphylaxis in China

Background:Wheat-dependent, exercise-induced anaphylaxis (WDEIA) is an allergic reaction induced by intense exercise combined with wheat ingestion. The gold standard for diagnosis of WDEIA is a food exercise challenge; however, this test is unacceptable for Chinese WDEIA patients and unable to be approved by the Ethics Committee of Chinese hospitals due to substantial risk. There are no diagnostic criteria for Chinese WDEIA patients. The aim of present study was to propose new practical diagnosis criteria for Chinese WDEIA patients.Methods:We prospectively included 283 clinically diagnosed WDEIA patients from January 1, 2010 to June 30, 2014, and in the meanwhile, three groups were enrolled which included 133 patients with the history of anaphylaxis induced by food other than wheat, 186 recurrent urticaria patients, and 94 healthy participants. Clinical comprehensive evaluation by allergists used as the reference gold standard, receiver operator characteristic (ROC) curves were plotted, areas under curve (AUC) for specific immunoglobin E (sIgE) were compared to evaluate the diagnostic value of IgE specific to wheat, gluten, and ω-5 gliadin. Patients were followed up by telephone questionnaire 1 year after diagnosis.Results:We reviewed 567 anaphylactic reactions in 283 WDEIA patients. Of these anaphylactic reactions, 415 (73.3%) reactions were potentially life-threatening anaphylaxis. Among the 567 anaphylactic reactions, 75% (425/567) occurred during exercise. The highest AUC (0.910) was observed for sIgE for gluten, followed by omega-5 gliadin (AUC 0.879). Combined gluten- and ω-5 gliadin-specific IgE testing provided sensitivity and specificity of 73.1% and 99.0%, respectively. During the 1-year follow-up period, repeat anaphylaxis was rare when patients observed strict avoidance of wheat products combined with exercise or other triggering agents.Conclusions:In this study, we proposed diagnostic criteria and management of WDEIA patients in China. Our present study suggested that confirmed anaphylactic reactions triggered by wheat with positive sIgE to gluten and omega-5-gliadin may provide supportive evidence for clinicians to make WDEIA diagnosis without performing a food exercise challenge.

Genome mapping of seed-borne allergens and immunoresponsive proteins in wheat.

Wheat is an important staple grain for humankind globally because of its end-use quality and nutritional properties and its adaptability to diverse climates. For a small proportion of the population, specific wheat proteins can trigger adverse immune responses and clinical manifestations such as celiac disease, wheat allergy, baker's asthma, and wheat-dependent exercise-induced anaphylaxis (WDEIA). Establishing the content and distribution of the immunostimulatory regions in wheat has been hampered by the complexity of the wheat genome and the lack of complete genome sequence information. We provide novel insights into the wheat grain proteins based on a comprehensive analysis and annotation of the wheat prolamin Pfam clan grain proteins and other non-prolamin allergens implicated in these disorders using the new International Wheat Genome Sequencing Consortium bread wheat reference genome sequence, RefSeq v1.0. Celiac disease and WDEIA genes are primarily expressed in the starchy endosperm and show wide variation in protein- and transcript-level expression in response to temperature stress. Nonspecific lipid transfer proteins and α-amylase trypsin inhibitor gene families, implicated in baker's asthma, are primarily expressed in the aleurone layer and transfer cells of grains and are more sensitive to cold temperature. The study establishes a new reference map for immunostimulatory wheat proteins and provides a fresh basis for selecting wheat lines and developing diagnostics for products with more favorable consumer attributes.

Wheat-Dependent Cofactor-Augmented Anaphylaxis: A Prospective Study of Exercise, Aspirin, and Alcohol Efficacy as Cofactors

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a severe and potentially life-threatening allergy caused by wheat ingestion and most commonly in combination with exercise. To investigate the role and impact of different cofactors (exercise, aspirin, and alcohol) in patients with WDEIA. We studied 25 adult patients with WDEIA. Diagnostic workup included specific IgE to omega-5 gliadin and skin prick test with wheat flour and gluten. Titrated oral challenge was performed with gluten at rest, combined with treadmill exercise, aspirin, alcohol, or a combination of exercise and aspirin. A positive challenge to gluten was found at rest (without cofactors) in 48% (12 of 25), with exercise in 92% (23 of 25), with aspirin in 84% (21 of 25), with alcohol in 56% (9 of 19), and with a combination of exercise and aspirin in 82% (18 of 22) of the patients. With exercise as a cofactor, the median threshold was 24 g (range, 4.8-80 g), with aspirin 8 g (range, 2.4-80 g), and with alcohol 28 g (range, 0-45 g). The combination of 2 cofactors (exercise and aspirin) resulted in a median threshold of 4.3 g (range, 1.1-48 g). The threshold for the clinical reaction was lowered by 63%, 83%, 36%, and 87%, respectively, compared with at rest. The mean severity grade (scale 0-5) according to the Sampson severity score at rest was 0.8 (range, 0-2), and when combined with exercise 2.1 (range, 0-5), with aspirin 1.9 (range, 0-5), with alcohol 0.8 (range, 0-2), and with the combination of exercise and aspirin 1.5 (range, 0-2). Our results demonstrate that exercise and aspirin augment clinical reactions in WDEIA by lowering the threshold and increase the severity of the allergic reaction, whereas alcohol gives ambiguous results. Furthermore, a combination of 2 cofactors (exercise and aspirin) increases therisk of reactions.

Proteomic Profiling and Epitope Analysis of the Complex α-, γ-, and ω-Gliadin Families in a Commercial Bread Wheat.

Wheat gliadins are a complex group of proteins that contribute to the functional properties of wheat flour doughs and contain epitopes that are relevant for celiac disease (CD) and wheat-dependent exercise-induced anaphylaxis (WDEIA). In this study, we extracted ethanol-soluble gliadin fractions from flour of the Korean bread wheat cultivar Keumkang. Proteins were separated by 2-dimensional gel electrophoresis (2-DE) using a pI range of 6–11 in the first dimension and subjected to tandem mass spectrometry. α-, γ-, and ω-gliadins were identified as the predominant proteins in 31, 28, and one 2-DE spot, respectively. An additional six ω-gliadins were identified in a separate experiment in which a pI range of 3–11 was used for protein separation. We analyzed the composition of CD- and WDEIA-relevant epitopes in the gliadin sequences from Keumkang flour, demonstrating the immunogenic potential of this cultivar. Detailed knowledge about the complement of gliadins accumulated in Keumkang flour provides the background necessary to devise either breeding or biotechnology strategies to improve the functional properties and reduce the adverse health effects of the flour.

898 Identification of allergens for wheat-dependent exercise-induced anaphylaxis developed by sensitization to grass pollen

898 Identification of allergens for wheat-dependent exercise-induced anaphylaxis developed by sensitization to grass pollen

Exercise Lowers Threshold and Increases Severity, but Wheat-Dependent, Exercise-Induced Anaphylaxis Can Be Elicited at Rest

Wheat-dependent, exercise-induced anaphylaxis (WDEIA) is a severe form of allergy in which exercise is being considered as mandatory. The diagnosis is often complex and the clinical reproducibility low. The aims of this study were to establish a standardized challenge method for the diagnosis of WDEIA and to investigate whether exercise is an essential trigger factor or alternatively an augmentation factor able to lower threshold and increase severity. We investigated 71 patients (age, 18.6-73.7 years) with a case history of WDEIA. Skin prick test (SPT) and measurement of specific IgE (sIgE) were followed by an oral food challenge with gluten at rest and in combination with treadmill exercise. A clinical reaction was elicited in 47 of 71 (66%), and in 26 of these (37%) the reaction could be elicited at rest. The median dose required at rest was 48 g (8-80 g) and in combination with exercise 24 g (4-80 g). Severity was significantly higher with exercise (2.3) than at rest (1.1) using Sampson severity score. In the challenge, SPT was positive to wheat in 93.6% (44 of 47) and to gluten in 95.7% (45 of 47). sIgE to wheat, gliadin, and omega-5 gliadin was present in 78.7% (37 of 47), 76.5% (36 of 47), and 91.4% (43 of 47) of the patients. Receiver operating characteristic-curve analysis for sIgE to omega-5 gliadin, a component of the gluten fraction and the major allergen in WDEIA, showed best sensitivity (91%) and specificity (92%) when gluten was combined with exercise. A challenge test with gluten at rest and combined exercise is a safe confirmatory test for WDEIA. A reaction can be elicited at rest (without exercise), but exercise is able to lower the threshold and increase the severity.