1
|
Poziomkowska-Gęsicka I, Kostrzewska M, Kurek M. Comorbidities and Cofactors of Anaphylaxis in Patients with Moderate to Severe Anaphylaxis. Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18010333. [PMID: 33466336 PMCID: PMC7794698 DOI: 10.3390/ijerph18010333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 12/19/2022]
Abstract
Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes and cofactors of this reaction. This paper presents the analysis of data from the Anaphylaxis Registry gathered over ten years at the Allergy Clinic, Pomeranian Medical University (PMU). A questionnaire-based survey was used for patients visiting the Allergy Clinic to identify potential augmentation factors/comorbidities and/or cofactors of anaphylaxis in patients with a history of moderate to severe anaphylaxis. The registry comprised patients with grade II or higher anaphylaxis. The gathered data concerned chronic comorbidities (cardiovascular diseases, respiratory diseases, and others), recurrence of anaphylaxis, and potential cofactors in anaphylaxis. In the analyzed group, the incidence rate of anaphylaxis was the highest for women aged 19–60 years. Most common comorbidities in patients with moderate to severe anaphylaxis included: cardiovascular diseases, respiratory tract diseases, features of atopy, and thyroid diseases. More than 30% of drug-induced reactions were anaphylactic reactions due to the re-exposure to the same drug, which points to the need for educational initiatives in this area. The incidence rate of anaphylaxis induced by Hymenoptera stings was comparable in patients who had a previous generalized reaction and those who had good tolerance to the previous sting. It is important to take these cofactors into consideration when evaluating patients with anaphylaxis as they may play a role in future anaphylactic reactions.
Collapse
Affiliation(s)
- Iwona Poziomkowska-Gęsicka
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, 70-204 Szczecin, Poland;
- Correspondence:
| | - Magdalena Kostrzewska
- Department of Pulmonology, Allergology and Respiratory Oncology, University of Medical Sciences, 60-569 Poznan, Poland;
| | - Michał Kurek
- Clinical Allergology Department, Pomeranian Medical University (PMU) in Szczecin, 70-204 Szczecin, Poland;
| |
Collapse
|
2
|
Christensen MJ, Eller E, Mortz CG, Brockow K, Bindslev-Jensen C. Exercise Lowers Threshold and Increases Severity, but Wheat-Dependent, Exercise-Induced Anaphylaxis Can Be Elicited at Rest. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019. [PMID: 29524997 DOI: 10.1016/j.jaip.2017.12.023] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND 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. OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Morten J Christensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense C, Denmark.
| | - Esben Eller
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense C, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense C, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense C, Denmark; Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense C, Denmark
| |
Collapse
|
3
|
Agulló-García A, Cubero Saldaña J, Colás Sanz C. Series of 12 cases of wheat-dependent exercise-induced allergy in Aragon, Spain. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2018.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
4
|
Agulló-García A, Cubero Saldaña JL, Colás Sanz C. Series of 12 cases of wheat-dependent exercise-induced allergy in Aragon, Spain. Rev Clin Esp 2019; 219:184-188. [PMID: 30651196 DOI: 10.1016/j.rce.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/20/2018] [Accepted: 11/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES The 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 METHODS A descriptive, retrospective study was conducted by reviewing the medical records of 12 patients diagnosed with ω-5G hypersensitivity. RESULTS The 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. CONCLUSIONS WDEIA is a relatively rare but potentially severe food allergy. Understanding this allergy is therefore important for a correct diagnosis.
Collapse
Affiliation(s)
- A Agulló-García
- Servicio de Alergología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España.
| | - J L Cubero Saldaña
- Servicio de Alergología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
| | - C Colás Sanz
- Servicio de Alergología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, España
| |
Collapse
|
5
|
Christensen MJ, Eller E, Kjaer HF, Broesby-Olsen S, Mortz CG, Bindslev-Jensen C. Exercise-induced anaphylaxis: causes, consequences, and management recommendations. Expert Rev Clin Immunol 2019; 15:265-273. [DOI: 10.1080/1744666x.2019.1562904] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Morten J. Christensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Esben Eller
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Henrik F. Kjaer
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Sigurd Broesby-Olsen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Charlotte G. Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| |
Collapse
|
6
|
Giannetti MP. Exercise-Induced Anaphylaxis: Literature Review and Recent Updates. Curr Allergy Asthma Rep 2018; 18:72. [PMID: 30367321 DOI: 10.1007/s11882-018-0830-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW This paper will review the pathophysiology, diagnosis, and treatment of exercise-induced anaphylaxis and food-dependent, exercise-induced anaphylaxis with an emphasis on novel studies published in the past several years. RECENT FINDINGS Exercise-induced anaphylaxis (EIAn) is a clinical syndrome characterized by anaphylaxis during or shortly after physical exertion. The syndrome is broadly grouped into two categories: exercise-induced anaphylaxis and food-dependent, exercise-induced anaphylaxis (FDEIAn). Recent literature indicates that FDEIAn is a primary IgE-mediated food allergy which is augmented by several cofactors. Cofactors such as exercise, NSAIDs, and alcohol increase intestinal permeability and allow increased antigen uptake, thereby causing symptoms. The pathophysiology of EIAn is still under investigation. EIAn and FDEIAn are rare clinical syndromes characterized by symptoms during or shortly after exercise. Despite recent advances in the understanding of EIAn and FDEIAn, the pathophysiology of both conditions is not fully understood.
Collapse
Affiliation(s)
- Matthew P Giannetti
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, 60 Fenwood Rd., Building for Transformative Medicine, 5th Floor, Boston, MA, 02115, USA.
| |
Collapse
|
7
|
Christensen MJ, Eller E, Mortz CG, Brockow K, Bindslev-Jensen C. Wheat-Dependent Cofactor-Augmented Anaphylaxis: A Prospective Study of Exercise, Aspirin, and Alcohol Efficacy as Cofactors. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:114-121. [PMID: 30599881 DOI: 10.1016/j.jaip.2018.06.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/23/2018] [Accepted: 06/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND 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. OBJECTIVE To investigate the role and impact of different cofactors (exercise, aspirin, and alcohol) in patients with WDEIA. METHODS 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. RESULTS 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). CONCLUSION 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 the risk of reactions.
Collapse
Affiliation(s)
- Morten J Christensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense, Denmark.
| | - Esben Eller
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense, Denmark
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis, Odense University Hospital, Odense, Denmark
| |
Collapse
|
8
|
Vasconcelos MJ, Delgado L, Silva D. Food-Dependent Exercise-Induced Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0171-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
9
|
Le TA, Al Kindi M, Tan JA, Smith A, Heddle RJ, Kette FE, Hissaria P, Smith WB. The clinical spectrum of omega-5-gliadin allergy. Intern Med J 2017; 46:710-6. [PMID: 27059930 DOI: 10.1111/imj.13091] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/17/2016] [Accepted: 03/29/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND IgE-mediated allergy to the wheat protein omega-5-gliadin (O5G) is associated with wheat-dependent exercise-induced anaphylaxis (WDEIA), where exercise acts as a cofactor, triggering anaphylaxis after wheat ingestion. The wider application of O5G-specific IgE (sIgE) testing has revealed that the manifestations of O5G allergy extend beyond WDEIA. AIMS This study documents clinical manifestations in a large series of patients with sIgE to O5G. METHODS A retrospective clinical audit was performed on adult patients with a positive O5G sIgE (>0.35kU/L) between 2007 and 2013 compared with a group who had negative O5G sIgE. Clinical characteristics and skin prick test (SPT) results were examined. RESULTS Sixty-seven patients were characterised, 26 of whom presented with food-dependent exercise-induced allergy, whilst others presented with exercise-induced symptoms without apparent food association (16/67), idiopathic anaphylaxis (10/67), food-induced allergic symptoms without exercise (10/67) or recurrent acute urticaria (5/67). Specific IgE to O5G had 91% sensitivity and 92% specificity for wheat-related allergic symptoms. SPT had sensitivity of 92% and specificity of 84%. CONCLUSION WDEIA is the most common manifestation of O5G allergy, but patients may present with a variety of allergic manifestations, and wheat allergy is not always obvious on history. Non-exercise cofactors or a lack of cofactors were identified in many patients. A distinctive feature of this allergy is that despite regular wheat ingestion, allergic reactions to wheat occur infrequently. Testing for sIgE to O5G should be considered in patients presenting with exercise-induced urticaria/anaphylaxis, idiopathic anaphylaxis and recurrent acute (but not chronic) urticaria.
Collapse
Affiliation(s)
- T A Le
- Division of Human Immunology, SA Pathology, Adelaide, South Australia, Australia.,Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - M Al Kindi
- Division of Human Immunology, SA Pathology, Adelaide, South Australia, Australia
| | - J-A Tan
- Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - A Smith
- Allergy and Clinical Immunology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - R J Heddle
- Division of Human Immunology, SA Pathology, Adelaide, South Australia, Australia.,Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - F E Kette
- Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - P Hissaria
- Division of Human Immunology, SA Pathology, Adelaide, South Australia, Australia.,Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - W B Smith
- Clinical Immunology and Allergy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
10
|
Scherf KA, Brockow K, Biedermann T, Koehler P, Wieser H. Wheat-dependent exercise-induced anaphylaxis. Clin Exp Allergy 2016; 46:10-20. [PMID: 26381478 DOI: 10.1111/cea.12640] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/05/2015] [Accepted: 09/13/2015] [Indexed: 12/31/2022]
Abstract
Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare, but potentially severe food allergy exclusively occurring when wheat ingestion is accompanied by augmenting cofactors. It is clinically characterized by anaphylactic reactions ranging from urticaria and angioedema to dyspnoea, hypotension, collapse, and shock. WDEIA usually develops after ingestion of wheat products followed by physical exercise. Other cofactors are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, alcohol, and infections. The precise mechanisms of WDEIA remain unclear; exercise and other cofactors might increase gastrointestinal allergen permeability and osmolality, redistribute blood flow, or lower the threshold for IgE-mediated mast cell degranulation. Among wheat proteins, ω5-gliadin and high-molecular-weight glutenin subunits have been reported to be the major allergens. In some patients, WDEIA has been discussed to be caused by epicutaneous sensitization with hydrolysed wheat gluten included in cosmetics. Diagnosis is made based on the patient's history in combination with allergy skin testing, determination of wheat-specific IgE serum antibodies, basophil activation test, histamine release test, and/or exercise challenge test. Acute treatment includes application of adrenaline or antihistamines. The most reliable prophylaxis of WDEIA is a gluten-free diet. In less severe cases, a strict limitation of wheat ingestion before exercise and avoidance of other cofactors may be sufficient.
Collapse
Affiliation(s)
- K A Scherf
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| | - K Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - T Biedermann
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - P Koehler
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| | - H Wieser
- Deutsche Forschungsanstalt für Lebensmittelchemie, Leibniz Institut, Freising, Germany
| |
Collapse
|
11
|
Asaumi T, Yanagida N, Sato S, Shukuya A, Nishino M, Ebisawa M. Provocation tests for the diagnosis of food-dependent exercise-induced anaphylaxis. Pediatr Allergy Immunol 2016; 27:44-9. [PMID: 26360640 DOI: 10.1111/pai.12489] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little has been reported regarding provocation tests for the diagnosis of food-dependent exercise-induced anaphylaxis (FDEIA), especially in children and adolescents. Hence, we here aimed to examine the usefulness and safety of such tests for FDEIA. METHODS We retrospectively analyzed 41 patients with 184 provocation tests. The patients underwent ergometer stress tests after ingesting the suspected foods along with aspirin. When one or more allergic symptoms appeared, we judged the provocation test as positive. RESULTS Based on 30 positive test results (16%), we diagnosed 20 patients (49%) as FDEIA. The major causative foods were as follows: wheat alone (five patients), combination of wheat and shrimp (three patients), combination of wheat and apple (two patients), and peach alone (two patients). The symptoms appeared within 45 min after initiating exercise in 29 tests (97%). The most frequent symptoms were cutaneous symptoms, which appeared in 25 tests (83%). Of the 30 positive tests, 6 (20%) required administration of adrenaline. After discharge, the patients with negative test results had no episodes of FDEIA due to the suspected foods that they had been tested for. CONCLUSION Provocation tests enabled us to confirm the diagnosis of FDEIA when positive and to exclude the diagnosis when negative. However, as severe symptoms may appear, these tests should be performed in a hospital under constant supervision of a physician.
Collapse
Affiliation(s)
- Tomoyuki Asaumi
- Department of Pediatrics, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Noriyuki Yanagida
- Department of Pediatrics, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Sakura Sato
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | | | - Makoto Nishino
- Department of Pediatrics, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy and Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa, Japan
| |
Collapse
|
12
|
Smith PK, Hourihane JO, Lieberman P. Risk multipliers for severe food anaphylaxis. World Allergy Organ J 2015; 8:30. [PMID: 26635908 PMCID: PMC4657220 DOI: 10.1186/s40413-015-0081-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/25/2015] [Indexed: 12/03/2022] Open
Abstract
Anaphylaxis is a severe, life threatening allergic reaction. In most fatal cases of food anaphylaxis, the fatality is not due merely to a simple, linear relationship between the allergen and exposure in a sensitized individual. Compounding factors such as the allergic disease burden—particularly the presence of asthma; comprehension of the potential severity of an event, training in the appropriate use of epinephrine, and emerging metabolic factors should be considered when assessing risk and establishing management strategies. This paper reviews the factors that contribute to the risk of severe anaphylactic events and provides a framework for the ongoing management of patients at risk of severe food allergy.
Collapse
Affiliation(s)
| | | | - Phil Lieberman
- University of Tennessee College of Medicine, Memphis, Tennessee USA
| |
Collapse
|
13
|
Burnell FJ, Keijzers G, Smith P. Review article: quality of follow-up care for anaphylaxis in the emergency department. Emerg Med Australas 2015; 27:387-93. [PMID: 26315372 DOI: 10.1111/1742-6723.12458] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2015] [Indexed: 11/28/2022]
Abstract
The prevalence of allergic disorders is rising, with a corresponding increase in patients presenting to an ED with anaphylaxis. Appropriate follow up is required for patients with anaphylaxis. We reviewed two potential performance indicators for the quality of post-discharge care: (i) the rate of self-injectable adrenaline prescription; and (ii) the referral rate for follow-up care with allergy specialists. A search of Cochrane Library, PubMed and Google Scholar was performed using the following initial search string: anaphylaxis and 'emergency department'. We considered any (interventional or observational design) study assessing post-discharge care in anaphylaxis, measured by either adrenaline self-injection prescription or allergist referral. Subjects were patients with (suspected) anaphylaxis or severe allergic reaction, with no age limit. This review summarises findings from 16 relevant papers, all retrospective analyses of post-discharge care for anaphylaxis. Weighted arithmetic means were calculated for rates of prescription of adrenaline auto-injector and referral to an allergist following admission to an ED in patients with (suspected) anaphylaxis or severe allergic reaction. Prescription rates for self-injected adrenaline at the time of discharge following anaphylaxis varied from 0% to 68%, with a mean of 44%. Allergist referral rates ranged from 0% to 84%, with a mean of 33%. This review demonstrates that there is room for improvement in post-discharge care for patients who present to the ED with an anaphylactic reaction.
Collapse
Affiliation(s)
- Fiona J Burnell
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Pete Smith
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
14
|
Brockow K, Kneissl D, Valentini L, Zelger O, Grosber M, Kugler C, Werich M, Darsow U, Matsuo H, Morita E, Ring J. Using a gluten oral food challenge protocol to improve diagnosis of wheat-dependent exercise-induced anaphylaxis. J Allergy Clin Immunol 2014; 135:977-984.e4. [PMID: 25269870 DOI: 10.1016/j.jaci.2014.08.024] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 08/05/2014] [Accepted: 08/21/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Oral wheat plus cofactors challenge tests in patients with wheat-dependent exercise-induced anaphylaxis (WDEIA) produce unreliable results. OBJECTIVE We sought to confirm WDEIA diagnosis by using oral gluten flour plus cofactors challenge, to determine the amount of gluten required to elicit symptoms, and to correlate these results with plasma gliadin levels, gastrointestinal permeability, and allergologic parameters. METHODS Sixteen of 34 patients with a history of WDEIA and ω5-gliadin IgE underwent prospective oral challenge tests with gluten with or without cofactors until objective symptoms developed. Gluten reaction threshold levels, plasma gliadin concentrations, gastrointestinal permeability, sensitivities and specificities for skin prick tests, and specific IgE levels were ascertained in patients and 38 control subjects. RESULTS In 16 of 16 patients (8 female and 8 male patients; age, 23-76 years), WDEIA was confirmed by challenges with gluten alone (n = 4) or gluten plus cofactors (n = 12), including 4 patients with previous negative wheat challenge results. Higher gluten doses or acetylsalicylic acid (ASA) plus alcohol instead of physical exercise were cofactors in 2 retested patients. The cofactors ASA plus alcohol and exercise increased plasma gliadin levels (P < .03). Positive challenge results developed after a variable period of time at peak or when the plateau plasma gliadin level was attained. Positive plasma gliadin threshold levels differed by greater than 100-fold and ranged from 15 to 2111 pg/mL (median, 628 pg/mL). The clinical history, IgE gliadin level, and baseline gastrointestinal level were not predictive of the outcomes of the challenge tests. The challenge-confirmed sensitivity and specificity of gluten skin prick tests was 100% and 96%, respectively. CONCLUSION Oral challenge with gluten alone or along with ASA and alcohol is a sensitive and specific test for the diagnosis of WDEIA. Exercise is not an essential trigger for the onset of symptoms in patients with WDEIA.
Collapse
Affiliation(s)
- Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany.
| | - Daniel Kneissl
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Luzia Valentini
- Department of Gastroenterology and Hepatology, Section of Nutritional Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Otto Zelger
- Department for Prevention, Rehabilitation and Sports Medicine, Technische Universität München, Munich, Germany
| | - Martine Grosber
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Claudia Kugler
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Martina Werich
- Department of Gastroenterology and Hepatology, Section of Nutritional Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf Darsow
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| | - Hiroaki Matsuo
- Department of Pathophysiology and Therapeutics, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Eishin Morita
- Department of Dermatology, Faculty of Medicine, Shimane University, Izumo, Japan
| | - Johannes Ring
- Department of Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
| |
Collapse
|
15
|
Wheat-dependent exercise-induced anaphylaxis following laparoscopic adjustable gastric banding procedure associated with Helicobacter pylori infection. Eat Weight Disord 2014; 19:267-70. [PMID: 24385412 DOI: 10.1007/s40519-013-0093-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 12/19/2013] [Indexed: 10/25/2022] Open
Abstract
Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a special form of adult food allergy when allergic symptoms are elicited when triggering factor such as exercise is added after ingestion of wheat. Besides the molecular characteristics of wheat proteins, the gastric function is decisive for the allergenic potential. Alterations in the gastric milieu are frequently experienced during a lifetime either physiologically or as a result of gastrointestinal pathologies. Helicobacter pylori infection can lead to hypoacidity and enhance the sensitization risk for food allergens in adults. Gastric transit of food proteins and alterations in the gastric secretion can be disturbed after bariatric surgery such as the laparoscopic adjustable gastric binding (LAGB) procedure used commonly as therapy for morbid obesity. We report a case of WDEIA in a 42-year-old man with H. pylori positive gastritis, 2 years after bariatric surgery and no history of allergy previously. Our presented case strongly suggests that H. pylori-associated gastritis and gastric anatomy and functional changes after adjustable gastric banding lead to the alterations in gastric milieu and may contribute to a development of food allergy in previously non-sensitized patients.
Collapse
|
16
|
Wong GK, Krishna MT. Food-dependent exercise-induced anaphylaxis: is wheat unique? Curr Allergy Asthma Rep 2014; 13:639-44. [PMID: 24127054 DOI: 10.1007/s11882-013-0388-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- Gabriel K Wong
- Department of Allergy and Clinical Immunology, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Bordesley Green East, Birmingham, UK, B9 5SS
| | | |
Collapse
|
17
|
Hompes S, Dölle S, Grünhagen J, Grabenhenrich L, Worm M. Elicitors and co-factors in food-induced anaphylaxis in adults. Clin Transl Allergy 2013; 3:38. [PMID: 24262093 PMCID: PMC4176490 DOI: 10.1186/2045-7022-3-38] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Accepted: 10/29/2013] [Indexed: 11/10/2022] Open
Abstract
Food-induced anaphylaxis (FIA) in adults is often insufficiently diagnosed. One reason is related to the presence of co-factors like exercise, alcohol, additives and non-steroidal anti-inflammatory drugs. The objective of this analysis was to retrospectively investigate the role of co-factors in patients with FIA. 93 adult patients with suspected FIA underwent double-blind, placebo-controlled food challenges with suspected allergens and co-factors. The elicitors of anaphylaxis were identified in 44/93 patients. 27 patients reacted to food allergens upon challenge, 15 patients reacted only when a co-factor was co-exposed with the allergen. The most common identified allergens were celery (n = 7), soy, wheat (n = 4 each) and lupine (n = 3). Among the co-factors food additives (n = 8) and physical exercise (n = 6) were most frequent. In 10 patients more than one co-factor and/or more than one food allergen was necessary to elicit a positive reaction. The implementation of co-factors into the challenge protocol increases the identification rate of elicitors in adult food anaphylactic patients.
Collapse
Affiliation(s)
- Stephanie Hompes
- Department of Dermatology and Allergology, Allergy-Center-Charité, Charité - Universitätsmedizin Charitéplatz 1, 10117 Berlin, Germany.
| | | | | | | | | |
Collapse
|
18
|
Dölle S, Hompes S, Grünhagen J, Worm M. [Food-associated anaphylaxis. Data from the anaphylaxis registry]. Hautarzt 2012; 63:294-8. [PMID: 22430610 DOI: 10.1007/s00105-011-2265-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Severe allergic reactions are reported to the anaphylaxis registry in German-speaking countries. The data provides knowledge regarding the diagnosis and management of patients suffering from anaphylaxis. The ranking of the most frequent elicitors inducing anaphylaxis is age-dependent and also influenced by the group which is reporting the data. The list of food allergens inducing anaphylaxis also varies with age. In children and adolescents peanuts are common elicitors of food-dependent anaphylaxis: in adults wheat is the most frequent cause. Furthermore, the data from the anaphylaxis registry provides information about rare triggers, as well as alerting us to those causative agents which are increasing in frequency. The relevance of augmentation factors is most likely age-dependent, whereas co-morbidities including atopic diseases like atopic dermatitis and allergic asthma occur frequently in children suffering from food-dependent anaphylaxis. The present manuscript provides data on food allergens such as peas and cauliflower, which have been reported as rare causes of anaphylaxis.
Collapse
Affiliation(s)
- S Dölle
- Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | | | | | | |
Collapse
|
19
|
Morita E, Matsuo H, Chinuki Y, Takahashi H, Dahlström J, Tanaka A. Food-dependent exercise-induced anaphylaxis -importance of omega-5 gliadin and HMW-glutenin as causative antigens for wheat-dependent exercise-induced anaphylaxis-. Allergol Int 2009; 58:493-8. [PMID: 19847096 DOI: 10.2332/allergolint.09-rai-0125] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2009] [Indexed: 01/08/2023] Open
Abstract
Food-dependent exercise-induced anaphylaxis (FDEIA) is a special form of food allergy where a food-intake alone does not induce any symptoms. However, allergic symptoms are elicited when triggering factors such as exercise or aspirin-intake are added after ingestion of the causative food. The most frequent causative foodstuff in Japan is wheat. The triggering factors, both exercise and aspirin-intake, facilitate allergen absorption from the gastrointestinal tract, resulting in allergic symptoms in the patients with wheat-dependent exercise-induced anaphylaxis (WDEIA). Analysis using purified wheat proteins revealed that approximately 80% of the patients with WDEIA have IgE reacting to omega-5 gliadin and the remaining of the patients to high molecular weight glutenin (HMW-glutenin). Simultaneous measurement of specific IgE to omega-5 gliadin and HMW-glutenin was found to be highly useful in diagnosing WDEIA compared with the routine diagnostic system for wheat.
Collapse
Affiliation(s)
- Eishin Morita
- Department of Dermatology, Shimane University Faculty of Medicine, Shimane, Japan.
| | | | | | | | | | | |
Collapse
|