Frequency of food-dependent, exercise-induced anaphylaxis in Japanese junior-high-school students

A dangerous exercise lessons from food-dependent anaphylaxis for the physician

Exercise-induced anaphylaxis (EIA) and its subtype, food dependent exercise-induced anaphylaxis are uncommon and therefore underdiagnosed forms of physical allergy. Triggers include various degrees of exercise in combination with ingestion of specific food products. Treatment remains identical to that of IgE-mediated allergic reactions. The presentation is commonly underdiagnosed and caries significant fatality risk, and this case should raise the awareness of the attending physician.

Food-dependent exercise-induced anaphylaxis with negative allergy testing

Food-dependent exercise-induced anaphylaxis (FDEIA) is a disorder where exercise following allergen ingestion triggers anaphylaxis although exercise and allergen exposure are independently tolerated. The diagnosis of FDEIA is based on a characteristic clinical history. The culprit allergen is usually confirmed through the use of skin prick testing (SPT) serum-specific IgE levels and a food-exercise challenge. We present a case of FDEIA suggested by clinical history and open food-exercise challenge with negative specific IgE levels and SPT that highlights the challenges involved in diagnosing and managing this rare disorder.

Specific Oral Tolerance Induction Using IFN-Gamma in 2 Cases of Food-Dependent Exercise-Induced Anaphylaxis

Anaphylaxis induced by exercise after the intake of certain foods is referred to as food-dependent exercise-induced anaphylaxis (FDEIA). Only the preventive medication such as oral sodium cromoglycate and oral combined cetirizine-montelukast was tried in FDEIA. Specific oral tolerance induction (SOTI) using IFN-gamma was tried in 2 cases of FDEIA for wheat. Merely, exercise accompanied every treatment just after the intake of allergenic foods during treatment. Patients acquired tolerance for wheat in both cases successfully. After treatment, two patients take wheat in their food living freely. Conclusively, SOTI using IFN-gamma was effective as the causative treatment for allergenic foods in FDEIA.

Exercise-induced anaphylaxis: a case report and review of the diagnosis and treatment of a rare but potentially life-threatening syndrome

A 24-year-old male Marine with an uncomplicated medical history and a long history of strenuous, daily exercise presented to the emergency department after experiencing anaphylactic shock while running. Symptoms resolved following administration of intramuscular diphenhydramine, ranitidine, intravenous methylprednisolone, and intravenous fluids. On followup in the allergy clinic, a meticulous clinical history was obtained which elucidated a picture consistent with exercise-induced anaphylaxis. He had experienced diffuse pruritus and urticaria while exercising on multiple occasions over the last three years. His symptoms would usually increase as exercise continued. Prior to the first episode, he regularly exercised without symptoms. Exercise-induced anaphylaxis is a rare but potentially life-threatening syndrome that requires a careful clinical history and is a diagnosis of exclusion. Treatment is primarily exercise avoidance. Prophylactic mediations are inconsistently effective but are empirically used. Successful treatment with omalizumab was recently reported in a case of refractory exercise-induced anaphylaxis.

Proposed new mechanism for food and exercise induced anaphylaxis based on case studies

We present two cases of food and exercise-induced anaphylaxis (FEIA) in patients with a diagnosis of oral allergy syndrome (OAS) to the implicated foods. Patient A had FEIA attributed to fresh coriander and tomato and Patient B to fresh celery. These food allergens have been implicated in OAS and have structural antigenic similarity to that of birch and/or grass. Both patients' allergies were confirmed by fresh skin prick tests. In both cases, strenuous exercise was antecedent to the systemic anaphylaxis reaction and subsequent ingestion without exercise produced only local symptoms of perioral pruritus. We review the current proposed mechanisms for food and exercise induced anaphylaxis to oral allergens and propose a novel and more biologically plausible mechanism. We hypothesize that the inhibitory effects of exercise on gastric acid secretion decreases the digestion of oral allergens and preserves structural integrity, thereby allowing continued systemic absorption of the allergen whether it be profilins, lipid transfer proteins, or other antigenic determinants.

Anaphylaxis in a tertiary adult allergy clinic: a retrospective review of 516 patients

BACKGROUND

Anaphylaxis is a life-threatening acute allergic reaction that can occur at any age.

OBJECTIVE

To determine the frequency, triggering factors, and clinical features of anaphylaxis among adult patients who were referred to a tertiary health care facility.

METHODS

A retrospective medical chart review was performed including all patients referred to the outpatient clinic of the adult allergy department in our university hospital between January 1, 2008 and December 30, 2011 to determine cases involving anaphylaxis.

RESULTS

A total of 516 (2.11%) patients among 24,443 admissions were diagnosed with anaphylaxis. Although the second highest frequency of anaphylaxis cases took place in 2008, a gradual rise in the frequency was determined from 2009 to 2011. Drugs (90.7%) were the most frequent cause, followed by Hymenoptera stings (5.4%), foods (1.6%), latex (0.4%), and exercise (0.2%) respectively. The clinical manifestations during anaphylaxis reported by patients were cutaneous (n = 292, 56.6%), respiratory (n = 253, 49%), cardiovascular (n = 212, 41%), neuropsychiatric (n = 60, 11.6%), and gastrointestinal (n = 52, 10.1%), respectively. Approximately one fifth of the patients received epinephrine, whereas 43% of patients did not receive epinephrine during their treatment in the emergency room. An epinephrine auto-injector was prescribed to 42 patients (8.1%).

CONCLUSION

In this study, the second pattern of National Institute of Allergy and Infectious Disease (NIAID) and the Food Allergy and Anaphylaxis Network (FAAN) diagnostic criteria for anaphylaxis predominated among adult patients. Drugs were the leading triggering factor, followed by Hymenoptera stings, foods, latex, and exercise, respectively. Atopy, asthma, and allergic rhinitis were rarely detected.

Exercise-induced anaphylaxis: A clinical view

Exercise-induced anaphylaxis (EIA) is a distinct form of physical allergy. The development of anaphylaxis during exertion often requires the concomitant exposure to triggering factors such as intake of foods (food dependent exercise-induced anaphylaxis) or drugs prior to exercise, extreme environmental conditions. EIA is a rare, but serious disorder, which is often undetected or inadequately treated. This article summarizes current evidences on pathophysiology, diagnosis and management. We reviewed recent advances in factors triggering the release of mediators from mast cells which seems to play a pathogenetic role. A correct diagnosis is essential to avoid unnecessary restricted diet, to allow physical activity in subjects with EIA dependent from triggering factors such as food, and to manage attacks. An algorithm for diagnosing EIA based on medical history, IgE tests and exercise challenge test has been provided. In the long-term management of EIA, there is a need for educating patients and care-givers to avoid exposure to precipitating factors and to recognize and treat episodes. Future researches on existing questions are discussed.

Food-dependent exercise-induced anaphylaxis occurred only in a warm but not in a cold environment

Food-dependent exercise-induced anaphylaxis (FDEIA) is a type of exercise-induced anaphylaxis associated with postprandial exercise. We describe a 19-year-old man with FDEIA. Our patient complained of urticaria, angioedema, dizziness and hypotension associated with exercise after ingestion of walnut-containing foods in a warm environment. Skin prick test and prick to prick test were positive for walnut antigen. The attack didn't occur by free running outside for 10 min 2 h after taking walnuts, and the temperature was about -2℃. Food-exercise test was done again in a warm environment based on prior history. Anaphylaxis was developed after exercise for 10 min in a warm environment after taking walnuts. Some environmental factors such as high temperature and high humidity or cold temperature may influence exercise-induced anaphylaxis. In our case, the cofactor was a warm environment: the challenge test done in a cold environment was negative, but positive in a warm environment. Physicians should be aware that the challenge test of FDEIA can show different results depending on temperature.

Prevalence of wheat allergy in Japanese adults

BACKGROUND

Wheat is one of the most common causes of food allergies. The exact prevalence of wheat allergy has not been well delineated in Japanese adults.

METHODS

We enrolled 935 adults in a cohort study established by Shimane University in order to examine the determinants of lifestyle-related diseases. A screening was conducted by a questionnaire-based examination and a detection of serum omega-5 gliadin-specific IgE. Subjects who tested positive in the questionnaire-based examination and/or the serum omega-5 gliadin-specific IgE test were further examined by detailed interviews and skin prick tests.

RESULTS

A total of 22 subjects were picked up by the screening process, and 17 of these were further examined by secondary testing. Only two subjects were conclusively identified as having wheat allergy.

CONCLUSIONS

The prevalence of wheat allergy in Japanese adults was found to be 0.21% by using a combination of questionnaire-based examination, skin prick test and serum omega-5 gliadin-specific IgE test.

An update on epidemiology of anaphylaxis in children and adults

PURPOSE OF REVIEW

The purpose of the present review is to describe the epidemiology of food-induced, medication-induced, drug-induced, and insect sting-induced anaphylaxis; to summarize recent changes in the incidence of anaphylaxis internationally; and to discuss recent insights into potential risk factors for anaphylaxis.

RECENT FINDINGS

Recent studies confirm that the incidence of anaphylaxis, particularly food-induced anaphylaxis, is increasing world-wide. The rise in anaphylaxis incidence appears most pronounced in children under the age of 5 years, which is also the age group most at risk of hospitalization for food-induced anaphylaxis. Identification of factors that may increase the risk of episodes of anaphylaxis remains an important research priority. Recently, two large cohort studies using data from electronic medical records confirmed that individuals with asthma are at higher risk of anaphylaxis and those with severe asthma have the highest risk of all. With respect to modifiable lifestyle factors, several studies have demonstrated a link between latitude and anaphylaxis, with areas with less year-round sunlight reporting a higher prevalence of food-induced anaphylaxis.

SUMMARY

Reports of an increasing incidence of anaphylaxis internationally highlight the need for identification of modifiable risk factors for anaphylaxis. Emerging evidence suggests that low vitamin D levels may be associated with risk of anaphylaxis and food allergy; however, further studies are required to confirm this.

Japanese guideline for food allergy

Food allergy is defined as "a phenomenon in which adverse reactions (symptoms in skin, mucosal, digestive, respiratory systems, and anaphylactic reactions) are caused in living body through immunological mechanisms after intake of causative food." Various symptoms of food allergy occur in many organs. Food allergy falls into four general clinical types; 1) neonatal and infantile gastrointestinal allergy, 2) infantile atopic dermatitis associated with food allergy, 3) immediate symptoms (urticaria, anaphylaxis, etc.), and 4) food-dependent exercise-induced anaphylaxis and oral allergy syndrome (i.e., specific forms of immediate-type food allergy). Therapy for food allergy includes treatments of and prophylactic measures against hypersensitivity like anaphylaxis. A fundamental prophylactic measure is the elimination diet. However, elimination diets should be conducted only if they are inevitable because they places a burden on patients. For this purpose, it is highly important that causative foods are accurately identified. Many means to determine the causative foods are available, including history taking, skin prick test, antigen specific IgE antibodies in blood, basophil histamine release test, elimination diet test, oral food challenge test, etc. Of these, the oral food challenge test is the most reliable. However, it should be conducted under the supervision of experienced physicians because it may cause adverse reactions such as anaphylaxis.

Exercise-induced anaphylaxis: an update on diagnosis and treatment

Exercise-induced anaphylaxis (EIA) and food-dependent, exercise-induced anaphylaxis (FDEIA) are rare but potentially life-threatening clinical syndromes in which association with exercise is crucial. The range of triggering physical activities is broad, including as mild an effort as a stroll. EIA is not fully repeatable (ie, the same exercise may not always result in anaphylaxis in a given patient). In FDEIA, the combined ingestion of sensitizing food and exercise is necessary to precipitate symptoms. Clinical features and management do not differ significantly from other types of anaphylaxis. The pathophysiology of EIA and FDEIA is not fully understood. Different hypotheses concerning the possible influence of exercise on the development of anaphylactic symptoms are taken into consideration. These include increased gastrointestinal permeability, blood flow redistribution, and most likely increased osmolality. This article also describes current diagnostic and therapeutic possibilities, including changes in lifestyle and preventive properties of antiallergic drugs as well as acute treatment of these dangerous syndromes.

Pathophysiology, diagnosis and management of exercise-induced anaphylaxis

PURPOSE OF REVIEW

The aim of this review is to challenge the current opinions of the pathophysiological mechanisms that give rise to food dependent exercise-induced anaphylaxis (FDEIA) and to consider these mechanisms within the wider context of exercise physiology to further inform our understanding and treatment of this condition.

RECENT FINDINGS

Exercise-induced anaphylaxis (food dependent and nonfood dependent) is a clinical syndrome in which anaphylaxis occurs in conjunction with exercise. Given the rarity of the condition, our current understanding relies on the many case studies and reviews of the topic. The pathophysiology of FDEIA remains to be fully elucidated with well constructed trials but current working hypotheses to date involve alterations in plasma osmolaltiy and pH, tissue enzyme activity, blood flow redistribution, altered gastrointestinal permeability and facilitated epitope recognition/allergen binding.

SUMMARY

Implications for future research are the physiological changes that occur during exercise need deeper consideration to ensure that proposed mechanisms are realistic and actually occur within the time frame and exercise-intensity domain during which the reported FDEIA occurred. These theories must be tested rigorously with sufficiently powered studies if progress is to be made in determining the perplexing pathophysiology of FDEIA.

The diagnosis and management of anaphylaxis practice parameter: 2010 update

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

Effect of oral sodium cromoglycate in 2 children with food-dependent exercise-induced anaphylaxis (FDEIA)

Food-dependent exercise-induced anaphylaxis (FDEIA) was prevented from recurring in 2 children by sodium cromoglycate (SCG) before intake of the causative food. CASE 1: A 14-year-old girl who had suffered recurrent symptoms of anaphylaxis when she exercised after lunch. Radioallergosorbent test (RAST) was 1.49 UA/mL for wheat. She was advised to take SCG before lunch. In 2007, she ate bread at lunchtime without taking SCG and developed anaphylaxis. After this, she always took SCG and did not develop anaphylaxis. CASE 2: A 9-year-old boy who had recurrent symptoms of anaphylaxis when he exercised after lunch. RAST was 0.46 UA/mL for wheat. He started taking SCG before lunch. In June 2008, he forgot to take SCG and ate fu (a food made from wheat). He exercised after lunch and developed anaphylaxis. Since then, he has always taken SCG and has not developed anaphylaxis.

CONCLUSION

Our findings suggest that SCG prevents FDEIA caused by wheat allergy.

Wheat-dependent, Exercise-induced Anaphylaxis: A Successful Case of Prevention with Ketotifen

Food-dependent, exercise-induced anaphylaxis (FDEIA) is the triggering of anaphylaxis after ingestion of certain foods when followed by physical exercise. Symptoms vary from the typical generalized urticaria to severe allergic reactions. We report the case of a 20-year-old woman who had a 7-year history of recurrent wheals and dyspnea after ingesting several kinds of food (wheat, pork, and beef) along with physical exercise. Based on a provocation test, she was diagnosed with wheat-dependent, exercise-induced anaphylaxis. She was instructed to take 2 mg of ketotifen 2 hours before ingestion of wheat to prevent the symptoms, and subsequently the provocation test did not elicit wheals. We therefore prescribed ketotifen (1 mg twice a day). She has not had recurrent wheals or dyspnea for 6 months. We herein report an interesting case of wheat-dependent, exercise-induced anaphylaxis with successful prevention by ketotifen.

Exercise-induced anaphylaxis: a serious but preventable disorder

Described for the first time approximately 30 years ago, exercise-induced anaphylaxis is a rare disorder characterized by development of a severe allergic response occurring after mild-to-strenuous physical activity. This disorder is especially important to recognize with the recent increase in physical activity and health fitness fads. A number of predisposing factors (eg, prior ingestion of particular food groups) linked to exercise-induced anaphylaxis has been outlined over the years. Mechanisms governing the condition are still being unveiled, and it is likely that one mechanism involves mast cell degranulation and inflammatory mediator generation resulting from the biochemical effects of exercise, sometimes in the presence of an ingested allergen such that wheat or shell fish. Clinical manifestations usually occur after around 10 minutes of exercise, and follow a specific sequence, starting with pruritis and widespread urticarial lesions, evolving into a more typical anaphylactic picture with respiratory distress and vascular collapse. Fatality is exceedingly rare, with only one documented case in the literature. There is an overlap of symptoms with other syndromes (such as systemic mastocytosis and cholinergic urticaria), and these should be remembered when establishing a differential. Treatment of exercise-induced anaphylaxis consists of immediate stabilization geared toward the anaphylactic response with epinephrine and anti histamines. The patient needs to be educated on preventive measures and equipped with an epinephrine autoinjector in the event of an emergency. Exercise-induced anaphylaxis remains a potentially serious disorder, and the health care provider should be aware of its clinical features and effective management strategies.

KEYWORDS

anaphylaxis; allergy; exercise; hypotension; urticaria; asthma.

Gender difference, sex hormones, and immediate type hypersensitivity reactions

Gender differences in the development and prevalence of human diseases have long been recognized. Immense interest grows in the understanding of the role of sex hormones in the homeostasis of immunity. Asthma predominates in boys before puberty and this gender preference reverses after puberty and in adulthood, when adult women tend to have a more severe disease, often recalcitrant to treatment. Atopic eczema in preschool children shows insignificant gender difference or male preponderance in different studies, with more adult females suffering from atopic eczema. The limited data on the prevalence of immediate hypersensitivity to hymenoptera venom show controversial results. Discrepancy exists regarding the gender difference in food allergy, with females reporting significantly more allergic reactions in questionnaire studies. In general, adverse reactions to nonionic iodinated radiocontrast media are more commonly observed in females. The course of allergic diseases varies unpredictably during pregnancy, whereas hormone replacement therapy in postmenopausal women usually has a favorable influence on the course of asthma. Experiments in rodents confirm an effect of estrogens on mast cell activation and allergic sensitization, while progesterone is shown to suppress histamine release but potentiate IgE induction. Dehydroepiandrosterone may antagonize the production of Th2 cytokines but the effect of testosterone and the other androgens remains less defined. Actual data from human studies are lacking.

Epidemiologic and clinical features of anaphylaxis in Korea

BACKGROUND

Little is known about the characteristics of anaphylaxis in Korea or even in Asia.

OBJECTIVE

To evaluate the incidence of anaphylaxis and the clinical features of patients with anaphylaxis in a Korean tertiary care hospital.

METHODS

We performed a retrospective review from January 1, 2000, through July 31, 2006, of 138 patients with anaphylaxis, including inpatients, outpatients, and emergency department visitors, in the Seoul National University Hospital.

RESULTS

Among 978,146 patients, 138 (0.014%) had anaphylaxis. Two cardiopulmonary resuscitations were performed and 1 death occurred. The total mortality rate of anaphylactic patients was 0.0001%. The causes of anaphylaxes were drug (35.3%), food (21.3%), food-dependent exercise-induced (13.2%), idiopathic (13.2%), insect stings (11.8%), exercise induced (2.9%), blood products (1.5%), and latex (0.7%). Radiocontrast media and buckwheat were the leading causes of drug and food anaphylaxis, respectively. The organs most frequently involved in the anaphylaxis were cutaneous (95.7%), cardiovascular (76.8%), and respiratory (74.6%). The most common manifestations were dyspnea (71.3%), urticaria (81.9%), and angioedema (69.4%). Three of 138 patients (2.2%) had biphasic reactions.

CONCLUSIONS

The incidence, mortality rate, and clinical features of Korean patients with anaphylaxis were similar to rates for patients from other countries, despite some differences in causative agents.

Food-dependent exercise-induced anaphylaxis in childhood

The clinical syndrome of food-dependent exercise-induced anaphylaxis (FDEIA) is typified by the onset of anaphylaxis during (or soon after) exercise which was preceded by the ingestion of the causal food allergen/s. In FDEIA, both the food allergen/s and exercise are independently tolerated. FDEIA is an uncommon allergic condition in childhood, but nonetheless is an important differential diagnosis to be considered when faced by a child who has experienced exercise-associated anaphylaxis. The diagnosis of FDEIA is heavily dependent on the clinical history. Allergy tests may need to be performed to a broad panel of food and food additives. Modified exercise challenges (performed with and without prior ingestion of food) are frequently required as allergy test results frequently return low-positive results. A diagnosis of FDEIA facilitates the safe independent return to exercise and reintroduction of foods for patients who otherwise may unnecessarily avoid exercise and/or restrict their diet. The natural history of FDEIA is unknown; however, a safe return is usually achieved when the ingestion of the causal food allergen/s and exercise are separated.

Food-dependent exercise-induced anaphylaxis

Food-dependent exercise induced anaphylaxis (FDEIA) is a distinct form of food allergy induced by physical exercise. Symptoms are typically generalized urticaria and severe allergic reactions such as shock or hypotension. Whereas various food items are responsible for the development of FDEIA, wheat is reported to be the allergen with the highest frequency in Japan. Recently aspirin has been known to be an additional exacerbating factor. Skin tests and in vitro serum food-specific IgE assays are currently used, however their sensitivity and specificity are not always satisfactory. A challenge test consisting of ingestion of assumed food followed by intense physical exercise is the only reliable method to determine the causative food and to diagnose the disease. The challenge test is not always safe because in some cases the test induces an anaphylactic shock. So a reliable in vitro diagnostic method is necessary for the patients with FDEIA. We revealed that wheat omega-5 gliadin and high molecular weight glutenin subunit are major allergens in wheat-dependent exercise-induced anaphylaxis (WDEIA). A simultaneous detection of specific IgE to epitope sequences of both omega-5 gliadin and high molecular weight glutenin is found to achieve higher sensitivity and specificity compared with the in vitro serum food-specific IgE assays currently used for diagnosis of WDEIA. On the other hand, immunoreactive gliadins appeared in the sera of patients during the provocation test with both wheat-exercise and wheat-aspirin challenges in parallel with allergic symptoms. These findings suggest that FDEIA is IgE-mediated hypersensitivity reaction to foods and both exercise and aspirin facilitate allergen absorption from the gastrointestinal tract.

A pediatric case of anaphylaxis caused by matsutake mushroom (Tricholoma matsutake) ingestion

BACKGROUND

Anaphylaxis is one of the severest forms of allergic diseases. Some kinds of mushroom are known as causative allergens in food anaphylaxis. Matsutake mushroom (Tricholoma matsutake) is a typical edible mushroom available in autumn in Japan. We encountered an 8-year-old Japanese girl who developed anaphylaxis after ingesting matsutake mushrooms.

METHODS

We studied the case in detail, by measuring specific IgE antibodies and conducting skin tests, to confirm the diagnosis. We also detected seven cytokines and chemical mediators in the blood in order to study the pathophysiology of the anaphylaxis.

RESULTS

We diagnosed anaphylaxis caused by ingestion of matsutake mushrooms based on the following. A skin prick test showed a positive reaction to matsutake mushroom, and specific IgE antibody for matsutake mushroom extract was detected in the patient's serum by fluorometric ELISA. Blood levels of chemical mediators including histamine, ECP, tryptase and cytokines such as IL-6, IL-5 and IL-10 but not IFN-gamma also increased significantly during the allergic episode.

CONCLUSIONS

We demonstrated that chemical mediators including histamine, tryptase and ECP as well as several cytokines were involved significantly during the episode of anaphylaxis. In addition, eosinophils as well as mast cells played significant roles in the anaphylaxis. Furthermore, CD4+CD25+ T regulatory cells that released IL-10 were likely activated during the anaphylaxis. Matsutake mushroom should be considered as a causative allergen in food anaphylaxis.

Identification of IgE-binding epitopes on gliadins for patients with food allergy to wheat

BACKGROUND

Food allergy to wheat induces different symptoms as atopic eczema/dermatitis syndrome (AEDS), urticaria and more severe reactions as wheat-dependent exercise-induced anaphylaxis (WDEIA). Different gliadin classes are involved in this allergy but IgE-binding epitopes are known only on omega5-gliadins and for WDEIA cases.

OBJECTIVES

The aim of the study was to identify IgE-binding epitopes on several gliadin classes and for several patients with different symptoms and ages.

METHODS

Eleven sera were analysed by pepscan with overlapping synthetic peptides.

RESULTS

Sera from five patients with anaphylaxis, urticaria or WDEIA, displayed strong IgE-binding to sequential epitopes of the repetitive domains of alphabeta, gamma, omega2 or omega5-gliadins with two immunodominant epitopes on omega5-gliadin and a consensus motif of the type QQX1PX2QQ (X1 being L, F, S or I and X2 Q, E or G). One patient allergic to deamidated wheat proteins also had IgE to a repetitive peptide of gamma and omega2-gliadins of the type QPQQPFP. Sera from four patients with AEDS detected no linear epitopes on gliadins, despite the fact that they contained specific IgE to alpha, beta, gamma or omega-gliadins. One child with AEDS recognized cysteine-containing sequences in the nonrepetitive domains of alphabeta and gamma-gliadins.

CONCLUSION

B epitopes in wheat allergy were different from B epitopes of coeliac disease. Differences exist in IgE-binding epitopes between patients with food allergy to wheat. IgE from those suffering from WDEIA, anaphylaxis and urticaria detected sequential epitopes in the repetitive domain of gliadins whereas IgE from AEDS patients probably recognized conformational epitopes.

Cutaneous allergic reactions induced by sporting activities

This survey searched for allergic skin reactions associated with, and possibly resulting from, sporting or recreational activities. The goal was to develop profiles of the types of allergens and responses that might be expected in association with particular sports involvement. The data mainly derive from published reports of allergic-appearing skin responses occurring during and after sports participation. The majority of these are single or short series of cases. Some supplementary data from earlier reviews, and two cases from our own clinical experience, have also been incorporated. Given the scattered availability of published case material in this field, we have included most of the reports that came to our attention. We have indicated where the connection between the clinical response and the putative agent or sporting activity seems tenuous. The data are organised according to type of reaction (type I, immunoglobulin E-mediated, largely hives, angioedema and anaphylaxis; and type IV, cell-mediated, largely contact dermatitis). Some envenomations that may be amplified by allergy have also been included. In water sports, allergic sensitivity to equipment (wetsuits, masks, goggles), water per se and disinfecting agents, and various water-dwelling creatures was found. In team and other outdoor sports, most allergies related to shoes, braces/supports and other equipment, and occasionally to topical medicaments and other miscellaneous contactants. Sports participants encounter a variety of potential sensitisers. Of interest is whether a higher level of physical activity may put them at greater risk of becoming sensitised.

Exercise-induced Anaphylaxis

Exercise-induced anaphylaxis has been recognized with increasing frequency since its original description in 1980. Recent studies suggest food-induced reactions may occur frequently in this syndrome, which is a mast cell-dependent phenomenon. In this article, the clinical manifestations of exercise-induced anaphylaxis are reviewed, and food-related factors contributing to the disorder are considered.

Role of adverse reactions to food in urticaria and exercise-induced anaphylaxis

In urticaria, adverse reactions to food are only a frequent finding in the subset of patients with chronic continuous urticaria. Mostly these reactions are of pseudoallergic nature, directed against artificial additives as well as naturally occurring aromatic components. IgE-mediated allergic reactions are a rare cause in acute urticaria as well as in recurrent chronic urticaria. In other types of urticaria, e.g. physical urticaria, food plays hardly any role as an eliciting agent with the exception of ice-cold drinks in cold urticaria. By contrast, exercise-induced anaphylaxis is frequently food-dependent. Two subtypes are distinguished: unspecific food-dependent exercise-induced anaphylaxis (FDEIA), where the filling of the stomach independently of the kind of food ingested prior to exercise is responsible for the symptoms. In specific FDEIA, an IgE-mediated food allergy causes symptoms only in combination with exercise. In the latter group, wheat is an important allergen.