Exercise-induced Anaphylaxis

Severe exercise-induced anaphylaxis in a hot and humid area successfully treated with omalizumab: a case report

Exercise-induced anaphylaxis (EIA) is a rare disorder in which anaphylaxis occurs exclusively after physical activity. Here, we report a case of severe EIA where anaphylaxis was initially only induced by strenuous exercise. Suddenly the anaphylaxis got out of control to the degree that usual daily activities triggered it. Exposure to a hot and humid environment appeared to be a cofactor for the development of severe symptoms resistant to usual preventive measures. Treatment with omalizumab (anti-IgE) was initiated and resulted in marked improvement. We discuss unique aspects of this case in comparison to published information on the clinical features, triggering cofactors, diagnosis, and treatment of EIA.

Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns

Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.

Kidney-bean (Phaseolus Vulgaris) Dependent, Exercise-induced Anaphylaxis in Patients Comorbid with Mugwort (Artemisia Vulgaris) Pollinosis

Background: The cross-reactive allergen between mugwort (Artemisia vulgaris) and kidney bean (Phaseolus vulgaris) has not yet been identified.Methods: A total of 24 patients were included in this study. The sera of patients were analyzed for the concentrations of specific IgE antibodies. The allergenicity and cross-reactivity were investigated by Western blotting and immunoblot inhibitory experiments.Results: The immunoblotting indicated the binding of patients' IgE to crude mugwort extract at ~26 kDa protein (15 cases), ~60 kDa (15 cases), and 10-15 kDa proteins (12 cases). The results of the immunoblot-inhibition assay showed that kidney bean seed extract inhibited specific IgE binding to mugwort at 10-15 kDa, ~26 kDa, and ~60 kDa in 4 (16.7%), 1 (4.2%) and 2 (8.3%) cases, respectively. On the other hand, mugwort extract was demonstrated to inhibit specific IgE binding to kidney bean seed at 10-15 kDa, 15-20 kDa, ~30 kDa, and 60 kDa in 1 (4.2%), 3 (12.5%), 4 (16.7%), and 3 (12.5%) cases, respectively.Conclusion: The 26-30 kDa, 10-15 kDa, and 60 kDa proteins are potential causative agents of the cross-reactivity between mugwort and kidney beans. The findings of this study improved the current understanding on the allergenicity of kidney beans and would provide insights into the refinement of treatment strategy for anaphylaxis.

Diagnosis and prevention of food-dependent exercise-induced anaphylaxis

Introduction: Food-dependent, exercise-induced anaphylaxis (FDEIA) is a rare type of anaphylaxis with a growing incidence. Although the precise mechanism by which the patient reacts only in a combination of a culprit food and cofactors are not currently understood, many advances in diagnosis and management have been made since their first description. Areas covered: A literature search in PubMed was performed to review the diagnosis and management of FDEIA. Clinicians should have a high level of suspicion for identification of the culprit foods and the cofactors involved. Component-resolved diagnosis and more accurate provocation tests have revolutionized the diagnosis accuracy. Management is not easy and involves educating the patient to evict the combination of exposure to the culprit foods and the cofactors that elicit anaphylaxis, and how to act and treat if a reaction occurs. Expert opinion: FDEIA is currently misdiagnosed and the authors believe that there are many FDEIA patients labelled as idiopathic anaphylaxis with unnecessary evictions and with a poor quality of life because of the fear of an imminent reaction. Due to recent advances in diagnostic tools and the use of monoclonal antibodies for prophylaxis in persistent cases, FDEIA can have a better prognosis improving the quality of life of the patients and their families.

Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers

Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.

Diagnosis and management of anaphylaxis in precision medicine

Anaphylaxis is the most severe and frightening of the allergic reactions, placing patients at high risk and demanding prompt recognition and immediate management by health care providers. Yet because its symptoms imitate those of other diseases, such as asthma and urticaria, current data suggest that its diagnosis is often missed, with underuse of tryptase measurement; its treatment is delayed, with little use of epinephrine; and its underlying cause or causes are poorly investigated. Deaths from anaphylaxis are difficult to investigate because of miscoding. Surprisingly, patients treated with new and powerful chemotherapy agents and humanized mAbs present with nonclassical symptoms of anaphylaxis, and patients may present with unrecognized clonal mast cell disorders with KIT mutations may present as Hymenoptera-induced or idiopathic anaphylaxis. The goal of this review is to recognize the presentations of anaphylaxis with the description of its current phenotypes, to provide new insight and understanding of its mechanisms and causes through its endotypes, and to address its biomarkers for broad clinical use. Ultimately, the aim is to empower allergists and heath care providers with new tools that can help alleviate patients' symptoms, preventing and protecting them against anaphylaxis.

Cross-reactive LTP sensitization in food-dependent exercise-induced urticaria/anaphylaxis: a pilot study of a component-resolved and in vitro depletion approach

Background

Challenge tests for food-dependent exercise-induced anaphylaxis (FDEIA) carry some risk and have a high rate of false negatives. Our aim was to explore the usefulness of an in vitro immunodepletion assay and an allergen microarray test in the identification of IgE-mediated cross-reactive food allergens in patients with suspected FDEIA or food-dependent exercise-induced urticaria and panallergen sensitization.

Methods

Three patients with a history of food dependent exercise induced urticaria/anaphylaxis and food panallergen sensitization in whom a food-exercise challenge was not feasible were selected: a 25-year-old man with cholinergic urticaria who experienced generalized urticaria and angioedema during a soccer match after drinking a peach-based soft drink; a 19-year-old woman with allergic rhinitis and controlled asthma who experienced anaphylactic shock while playing soccer, having eaten walnuts in the previous 90 min; and a 57-year-old man with baker’s asthma who experienced four episodes of anaphylaxis during exercise after ingesting wheat-containing food. All individuals underwent a diagnostic work-up with skin prick tests, specific IgE (sIgE) and ImmunoCAP ISAC test. For the in vitro immunodepletion procedure, patients’ serum was pre-incubated with the suspected native allergen (peach, walnut, or wheat) in solid phase (ImmunoCAP). The eluted serum, containing unbound IgE, was collected and samples were re-tested using Immunocap ISAC 112 and compared with baseline results.

Results

All individuals were sensitized to lipid transfer proteins. The first patient was sensitized to Pru p 3, Cor a 8, Jug r 3, and Ara h 9; after pre-incubation with peach there was 100% depletion of sIgE to all components. The second patient was sensitized to Pru p 3, Cor a 8, Jug r 3, and Ara h 9; immunodepletion with walnut depleted sIgE to Ara h 9 by 67%, Pru p 3 and Pla a 3 (60%), Art v 3 (75%), Jug r 3 (88%), and Cor a 8 (100%). The third patient was sensitized to Pru p 3, Jug r 3, Ara h 9, and Tri a 14; immunodepletion with wheat depleted Tri a 14 only (100%).

Conclusions

In vitro immunodepletion might be a useful diagnostic tool in food dependent exercise induced urticaria/anaphylaxis with panallergen sensitization, particularly for identifying the culprit allergen and guiding dietary elimination recommendations.

Anaphylaxis and sport

PURPOSE OF REVIEW

This article aims to review the most relevant studies on exercise-induced anaphylaxis, published in the last year, in order to provide comprehensive and updated evidence and hopefully contribute to a better definition of its pathophysiological mechanisms and treatment strategies.

RECENT FINDINGS

The search strategy was performed from 1/2/2013 to 31/1/2014 by scanning the principal electronic bibliographic database and by hand-searching the main scientific publications in Allergy and Clinical Immunology. Among the identified articles, 17 articles were selected to be part of the systematic review. Eligible studies included five experimental trials, eight case reports and four letters.

SUMMARY

The overall collected evidence was of very low quality. No randomized controlled trials were identified by the searching process. Most of the data derived from reports performed in small population samples or even in individual cases. Except for one article addressing issues related to the preventive management of exercise-induced anaphylaxis, all other articles focused on prevalence rates, causative triggers and pathogenetic mechanisms. More interesting findings were related to the influence of the IL-4-C590T polymorphism on the onset of wheat-dependent exercise-induced anaphylaxis and to the usefulness of the immuno solid-phase allergen chip technique in the allergic screening of polysensityzed athletes at risk of severe reactions.

Food-dependent exercise-induced anaphylaxis: is wheat unique?

This review draws comparisons between wheat-dependent exercise-induced anaphylaxis (WDEIA) and other food-dependent exercise-induced anaphylaxis (FDEIAs) and discusses the importance of co-factors in its pathophysiology. FDEIA remains an enigmatic condition since it was first described 30 years ago. The sporadic and unpredictable nature of its reactions has puzzled clinicians and scientists for decades, but recent studies on WDEIA have enlightened us about the pathophysiology of this condition. The identification of defined allergic epitopes such as Tri a 19, α-gliadin, β-gliadin and γ-gliadin in WDEIA enables it to become the perfect model for studying FDEIA, but WDEIA is by no means a unique condition. On a larger scale, FDEIA represents a crucial link between IgE-mediated and anaphylactoid reactions and provides supportive evidence for the concept of 'summation anaphylaxis' and the need to overcome the 'allergen threshold'. Future work should focus on identifying more of the FDEIA epitopes and understanding their distinct molecular properties. The development of a biomarker in order to identify patients susceptible to co-factor influences would be invaluable.

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.

Allergy and sports in children

Physical activity is beneficial for children with positive outcomes for mental and physical well-being. Allergic conditions unique to the sporting arena may serve as an impediment to participation in physical activity for allergic children. A common example is exercise-induced asthma; less common activity-related allergic conditions include food-dependent exercise-induced anaphylaxis, exercise-induced anaphylaxis, and exercise-induced urticaria. Allergic children may also be at risk of allergic reactions when exposed to allergens that are more commonly found in the sports environment, e.g., latex, sports drinks, and medications such as NSAIDs. Recent advances in our understanding of the patho-physiological and immunologic mechanisms that may account for these conditions have facilitated more effective and safer management strategies. There are also important immunologic lessons to be learnt with respect to specific physical factors that may result in diminished allergen tolerance; indeed, these lessons may facilitate safer allergen desensitisation regimens. The role of the immune system in exercise-induced immunoallergic syndromes, clinical aspects, and diagnostic and therapeutic approaches are discussed in this review.

Food-dependent, exercise-induced gastrointestinal distress

Among athletes strenuous exercise, dehydration and gastric emptying (GE) delay are the main causes of gastrointestinal (GI) complaints, whereas gut ischemia is the main cause of their nausea, vomiting, abdominal pain and (blood) diarrhea. Additionally any factor that limits sweat evaporation, such as a hot and humid environment and/or body dehydration, has profound effects on muscle glycogen depletion and risk for heat illness. A serious underperfusion of the gut often leads to mucosal damage and enhanced permeability so as to hide blood loss, microbiota invasion (or endotoxemia) and food-born allergen absorption (with anaphylaxis). The goal of exercise rehydration is to intake more fluid orally than what is being lost in sweat. Sports drinks provide the addition of sodium and carbohydrates to assist with intestinal absorption of water and muscle-glycogen replenishment, respectively. However GE is proportionally slowed by carbohydrate-rich (hyperosmolar) solutions. On the other hand, in order to prevent hyponatremia, avoiding overhydration is recommended. Caregiver's responsibility would be to inform athletes about potential dangers of drinking too much water and also advise them to refrain from using hypertonic fluid replacements.

A rat model of exercise-induced asthma: a nonspecific response to a specific immunogen

Exercise-induced bronchoconstriction (EIB) is common; however, key aspects of its pathogenesis are still unclear. We investigated the feasibility of adapting an established animal model of asthma to investigate the earliest stages of EIB. The hypothesis was that a single exposure to a normally innocuous, and brief, exercise challenge could trigger EIB symptoms in rats previously sensitized to ovalbumin (OVA) but otherwise unchallenged. Brown-Norway rats were sensitized by intraperitoneal injection of OVA at 0 and 2 wk. At week 3, animals were exposed to either aerosolized OVA (SS) or exercise (EXS). A trained, blinded, clinical observer graded EIB by respiratory sounds. Plasma and lung cytokine levels were analyzed. No control rats with or without exercise (EX, CON) showed evidence of EIB. Eighty percent of the SS group demonstrated abnormal breath sounds upon exposure to aerosolized OVA. Approximately 30% of EXS rats sensitized to OVA but exposed only to exercise had abnormal breath sounds. Lung tissue levels of TNF-α, IL-1α, growth-related oncogene/keratinocyte/chemoattractant, and IFN-γ were significantly higher (P < 0.001) in the SS group, relative to all other groups. Changes in most of these cytokines were not notable in the EXS rats, suggesting a different mechanism of EIB. Remarkably, IFN-γ, but not the other cytokines measured, was significantly elevated following brief exercise in both sensitized and unsensitized rats. Exercise led to detectable breathing sound abnormalities in sensitized rats, but less severe than those observed following classical OVA challenge. Precisely how this immune crossover occurs is not known, but this model may be useful in elucidating essential mechanisms of EIB.

Lifestyle and the Respiratory Health of Children

This article offers a review of the potential influences of personal lifestyle on respiratory health in children, looking at both healthy individuals and those with respiratory disorders. As with many aspects of health, regular physical activity, an appropriate diet, and avoidance of obesity and cigarette smoke all contribute to optimal development of the healthy child. An active lifestyle is associated with greater static and dynamic lung volumes, greater efficiency of the ventilatory process, and an optimization of breathing patterns. The risk of upper respiratory infections is also reduced in those maintaining a moderate level of physical activity. Maternal smoking during pregnancy, as well as active and passive smoking, all have an adverse influence on lung function in the child, the largest effects being on dynamic lung volumes. The risk of developing asthma seems reduced in children who maintain a normal body mass and are physically active. A program of graded physical activity is of therapeutic value in a number of established respiratory conditions, including asthma, cystic fibrosis, and ventilatory impairment from neuromuscular disorders. Exercise carries a slight risk of fatalities from asthma and anaphylactic reactions. In designing an optimal physical activity program, it is also important to guard against the hazards of deep oronasal breathing, including the precipitation of bronchospasm by the inhalation of cold, dry air and pollens; an increased exposure to atmospheric pollutants (reducing and oxidant smog, fine and ultra-fine particulates, and carbon monoxide); and possible long-term dangers from chlorine derivatives in the atmosphere of indoor swimming pools.

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.

Clinical Immunology Review Series: An approach to the patient with allergy in childhood

Allergic conditions are common, with asthma being the most common chronic illness in childhood in most developed countries. Some 80% of asthmatic children are sensitized to aeroallergens, usually indoor animal dander and house dust mite. Some 80% of asthmatics also have rhinitis. Rhinitis and eczema receive less medical attention than asthma, but they can cause longterm morbidity and have substantial direct and indirect economic costs. Food allergy and anaphylaxis are increasingly recognised and are usually easily diagnosed and managed.Clinicians can use in vivo and in vitro measurements of allergen-specific immunoglobulin E to better time reintroduction of implicated foods. Specific parenteral and sublingual immunotherapy is widely practiced internationally but is uncommon in the UK. It may alter the natural history of aeroallergen reactive diseases in the upper and lower airways. Specific oral tolerance induction represents the current cutting edge in clinical allergy research. It remands resource intensive at present and cannot be adopted into routine clinical practice at this time.

Exercise-induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy)

Exercise-induced (EI) hypersensitivity disorders are significant problems for both recreational and competitive athletes. These include EI-asthma, EI-bronchoconstriction, EI-rhinitis, EI-anaphylaxis and EI-urticaria. A group of experts from the European Academy of Allergology and Clinical Immunology and the American Academy of Allergy Asthma and Immunology met to discuss the pathogenesis of these disorders and how to diagnose and treat them, and then to develop a consensus report. Key words (exercise with asthma, bronchoconstriction, rhinitis, urticaria or anaphylaxis) were used to search Medline, the Cochrane database and related websites through February 2008 to obtain pertinent information which, along with personal reference databases and institutional experience with these disorders, were used to develop this report. The goal is to provide physicians with guidance in the diagnosis, understanding and management of EI-hypersensitivity disorders to enable their patients to safely return to exercise-related activities.

Food-dependent exercise-induced anaphylaxis: a case related to chickpea ingestion and review

: Food-dependent exercise-induced anaphylaxis (FDEIA) is recognized as a distinct category of exercise-induced anaphylaxis (EIA) but is very likely underdiagnosed. This report describes a 41-year-old Indian woman who experienced two separate episodes of anaphylaxis while dancing after she had eaten chickpea-containing foods. The chickpea, a small legume, is a staple ingredient in culinary traditions from around the world, especially in India, the Middle East, and North Africa. Chickpea-containing dishes are also becoming more widespread in the Western world with the growing popularity of South Asian, Middle Eastern, and African cuisines. It is important to consider FDEIA in cases of unexplained anaphylaxis as reactions can occur several hours after ingesting the culprit food(s). Furthermore, no reaction occurs if a sensitized individual eats the culprit food(s) without exercising afterward; therefore, triggering foods can easily be overlooked. Current ideas on the pathophysiology, predisposing factors, workup, and treatment of FDEIA are also summarized here.

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.

Dangerous exercise: lessons learned from dysregulated inflammatory responses to physical activity

Exercise elicits an immunological “danger” type of stress and inflammatory response that, on occasion, becomes dysregulated and detrimental to health. Examples include anaphylaxis, exercise-induced asthma, overuse syndromes, and exacerbation of intercurrent illnesses. In dangerous exercise, the normal balance between pro- and anti-inflammatory responses is upset. A possible pathophysiological mechanism is characterized by the concept of exercise modulation of previously activated leukocytes. In this model, circulating leukocytes are rendered more responsive than normal to the immune stimulus of exercise. For example, in the case of exercise anaphylaxis, food-sensitized immune cells may be relatively innocuous until they are redistributed during exercise from gut-associated circulatory depots, like the spleen, into the central circulation. In the case of asthma, the prior activation of leukocytes may be the result of genetic or environmental factors. In the case of overuse syndromes, the normally short-lived neutrophil may, because of acidosis and hypoxia, inhibit apoptosis and play a role in prolongation of inflammation rather than healing. Dangerous exercise demonstrates that the stress/inflammatory response caused by physical activity is robust and sufficiently powerful, perhaps, to alter subsequent responses. These longer term effects may occur through as yet unexplored mechanisms of immune “tolerance” and/or by a training-associated reduction in the innate immune response to brief exercise. A better understanding of sometimes failed homeostatic physiological systems can lead to new insights with significant implication for clinical translation.

Influence of physical inactivity on the prevalence of hay fever

BACKGROUND

Atopic diseases constitute a major public health problem, increasing constantly in frequency and severity. While treatments are improving, the main cause for an increasing trend of hay fever and its definite triggers remain unclear. The aim of our study was to assess whether physical inactivity could be a risk factor for hay fever.

METHODS

We analysed data of a cohort of children aged 5-14 years at baseline (1992-1993) who were followed up until 2003-2005. Parental-reported information on physical activity (being active, doing sports) was obtained for 2429 children participating at the baseline survey (active: n = 1923; semi-active: n = 364; inactive: n = 142). A total of 1703 children (70.1%) were reapproached at least once during follow-up. Logistic regression models were applied to study associations between hay fever, allergic sensitization and physical activity, adjusted for potentially relevant confounders such as age, gender, study site, parental education, breastfeeding, crowding, daycare, dampness or visible moulds, contact to cats, current or prior environmental tobacco smoke exposure and parental atopy.

RESULTS

Significantly higher rates of hay fever were seen for inactive children [aOR 2.39 (95% CI 1.31-4.36) for baseline survey 1992-1993 and aOR 1.76 (95% CI 1.14-2.71) for the follow-up-period until 2005]. In addition, the relative risk of incident cases of hay fever increased depending on inactivity [aRR 1.50 (95% CI 1.05-2.13)]. No association was found between physical inactivity and allergic sensitization assessed by radioallergosorbent test determinations.

CONCLUSIONS

Although the underlying biological mechanisms could not be clarified, increasing physical activity in childhood is suggested to prevent hay fever.

[Food allergy]

Food allergy is a growing health issue; its prevalence has exponentially increased in the past years, and it is situated around 4-5% of the general population. Health professionals will frequently have to deal with the management of affected patients. Only a minor number of foods cause the majority of allergic reactions. In Spain, milk, egg and fish are the most frequent sensitizers in children with food allergy; in adults, fruits and nuts, followed by fish and sea-food are the main food allergens. Clinical manifestations range from mild cutaneous reactions to life-threatening anaphylaxis. Therefore, an accurate diagnosis is crucial, as well as a correct medical treatment of reactions. Furthermore, patients and care-givers should be instructed on allergen avoidance and on the use of emergency kits in case of accidental ingestion.

Exercise-induced rhinitis: a common disorder that adversely affects allergic and nonallergic athletes

BACKGROUND

Exercise is a well-established trigger for allergic disorders such as asthma, urticaria, and anaphylaxis, but the effect of exercise on rhinitis has not been well described.

OBJECTIVE

To survey individuals with and without nasal allergy who exercise regularly to determine the prevalence and nature of nasal symptoms induced by indoor exercise.

METHODS

An original, self-administered questionnaire to evaluate exercise-induced rhinitis (EIR) was distributed to adults who were receiving allergy immunotherapy at a community allergy practice and to members of a community athletic club. Nasal symptoms that occur indoors (runny nose, nasal congestion, postnasal drip) were primarily evaluated. Comparisons with outdoor EIR were determined. The perception of adverse effects of rhinitis on exercise was evaluated.

RESULTS

Sixty-six (40%) of the 164 patients indicated that their indoor EIR adversely affected athletic performance, and this finding occurred more frequently in patients with nasal allergy vs unaffected individuals (53.1% vs 27.7%; P = .009). Of the 61.0% who reported increased rhinitis with indoor exercise, rhinorrhea was the most common symptom experienced (48.8%). Indoor EIR occurred more frequently in patients with nasal allergy vs unaffected individuals (69.1% vs 53.0%; P = .04). Outdoor EIR occurred in 56.1% of the total population, and patients with nasal allergy reported significantly more rhinitis with outdoor exercise compared with unaffected individuals (71.6% vs 41.0%; P < .001).

CONCLUSIONS

Exercise-induced rhinitis, predominantly rhinorrhea, commonly occurs in athletes regardless of underlying nasal allergy. A history specific to indoor and outdoor exercise triggers needs to be part of the complete rhinitis history so that specific treatment can be directed.

Food allergy and additives: triggers in asthma

Exposure to food allergens can cause a varied pattern of respiratory symptoms, with allergic responses ranging from asthma symptoms to occupational asthma. Food allergy in a patient presenting as asthma tends to indicate a more severe disease constellation. Patients with underlying asthma experience more severe and life-threatening allergic food reactions. When a food reaction involves respiratory symptoms, it is almost always a more severe reaction compared with reactions that do not involve the respiratory tract. Susceptible patients may even react to a causative food on inhalation without ingestion. However, isolated asthma or rhinitis symptoms without concomitant cutaneous or gastrointestinal symptoms are rare events.