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Ridolo E, Barone A, Ottoni M, Peveri S, Montagni M, Nicoletta F. Factors and co-factors influencing clinical manifestations in nsLTPs allergy: between the good and the bad. FRONTIERS IN ALLERGY 2023; 4:1253304. [PMID: 37841053 PMCID: PMC10568476 DOI: 10.3389/falgy.2023.1253304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Non-specific lipid transfer proteins (nsLTPs) are a family of plant pan-allergens that represent the primary cause of food allergies in the Mediterranean area, characterized by a wide range of clinical manifestations, ranging from the total absence of symptoms up to anaphylaxis. This wide variety of symptoms is related to the intrinsic capacity of nsLTPs to cause an allergic reaction in a specific subject, but also to the presence of co-factors exacerbating (i.e., exercise, NSAIDs, PPIs, alcohol, cannabis, prolonged fasting, menstruation, acute infections, sleep deprivation, chronic urticaria) or protecting from (i.e., co-sensitization to PR10, profilin or polcalcin) severe reactions. In this picture, recognizing some nsLTPs-related peculiarities (i.e., route, type and number of sensitizations, concentration of the allergen, cross-reactions) and eventual co-factors may help the allergist to define the risk profile of the single patient, in order to promote the appropriate management of the allergy from dietary advices up to the prescription of life-saving epinephrine autoinjector.
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Affiliation(s)
- Erminia Ridolo
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Allergology Unit, University Hospital of Parma, Parma, Italy
| | | | - Martina Ottoni
- Allergology Unit, University Hospital of Parma, Parma, Italy
| | - Silvia Peveri
- Departmental Unit of Allergology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Marcello Montagni
- Departmental Unit of Allergology, Guglielmo da Saliceto Hospital, Piacenza, Italy
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de Silva R, Karunatilake C, Iddagoda J, Dasanayake D. Food allergy in Sri Lanka – A comparative study. World Allergy Organ J 2022; 15:100723. [DOI: 10.1016/j.waojou.2022.100723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
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Kulthanan K, Ungprasert P, Jirapongsananuruk O, Rujitharanawong C, Munprom K, Trakanwittayarak S, Pochanapan O, Panjapakkul W, Maurer M. Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2280-2296. [PMID: 35752432 DOI: 10.1016/j.jaip.2022.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/24/2022] [Accepted: 06/06/2022] [Indexed: 05/03/2023]
Abstract
BACKGROUND Food-dependent exercise-induced wheals, angioedema, and anaphylaxis remain insufficiently characterized. OBJECTIVE We systematically reviewed the literature on clinical manifestations, laboratory investigations, culprit foods, triggering exercise, comorbidities, and treatment outcomes. METHODS Using predefined search terms and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) recommendations, we searched 3 electronic databases to identify relevant literature published before July 2021. RESULTS Of 722 patients (median age 25 years; 55.4% male) from 231 studies (43 cohort studies, 15 cases series, and 173 case reports), 79.6% and 3.7% had anaphylaxis with and without wheals and/or angioedema, respectively. The remaining 16.6% had wheals and/or angioedema without anaphylaxis. The duration from eating to exercising and from exercising to symptom onset ranged from 5 minutes to 6 hours (median 1 hour) and from 5 minutes to 5 hours (median 30 minutes), respectively, and virtually all patients exercised within 4 hours after eating and developed symptoms within 1 hour after exercising. Wheat was the most common culprit food. Running was the most common trigger exercise. Most patients were atopic, and 1 in 3 had a history of urticaria. Aspirin and wheat-based products were the most frequent augmenting factors. On-demand antihistamines, corticosteroids, and epinephrine were commonly used and reported to be effective. Patients who stopped eating culprit foods before exercise no longer developed food-dependent exercise-induced allergic reactions. CONCLUSIONS Food-dependent exercise-induced allergic reactions are heterogeneous in their clinical manifestations, triggers, and response to treatment. Patients benefit from avoidance of culprit foods before exercise, which highlights the need for allergological diagnostic workup and guidance.
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Affiliation(s)
- Kanokvalai Kulthanan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patompong Ungprasert
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Orathai Jirapongsananuruk
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chuda Rujitharanawong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanyalak Munprom
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Oraya Pochanapan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Waratchaya Panjapakkul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Marcus Maurer
- Institute of Allergology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Fraunhofer Institute for Translational Medicine and Pharmacology (ITMP), Allergology and Immunology, Berlin, Germany.
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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.
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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;
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Benito-Garcia F, Ansotegui IJ, Morais-Almeida M. Diagnosis and prevention of food-dependent exercise-induced anaphylaxis. Expert Rev Clin Immunol 2019; 15:849-856. [PMID: 31305164 DOI: 10.1080/1744666x.2019.1642747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Abstract
PURPOSE OF REVIEW In recent years, the number of reports on food-dependent exercise-induced anaphylaxis (FDEIA) has been increasing. This review aims to describe the standard management of FDEIA including provocation tests and identify the issues that remain unclear. RECENT FINDINGS Provocation tests with aspirin for FDEIA enable us to confirm the definitive diagnosis and to make differential diagnosis. In some cases, FDEIA symptoms can be induced by aspirin and the causative food without exercise. Exercise may only be an augmenting factor of FDEIA, similar to aspirin or alcohol. SUMMARY The mechanisms of FDEIA development remain unclear. It has been suggested that in FDEIA, exercise lowers the threshold of a food allergy. Further research is needed to elucidate the mechanism of FDEIA and to establish strategies for effective disease management.
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Decuyper II, Rihs HP, Van Gasse AL, Elst J, De Puysseleyr L, Faber MA, Mertens C, Hagendorens MM, Sabato V, Bridts C, De Clerck L, Ebo DG. Cannabis allergy: what the clinician needs to know in 2019. Expert Rev Clin Immunol 2019; 15:599-606. [DOI: 10.1080/1744666x.2019.1600403] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ine Ilona Decuyper
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Pediatrics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Hans-Peter Rihs
- IPA—Institute for Prevention and Occupational Medicine, German Social Accident Insurance, Ruhr-University Bochum, Bochum, Germany
| | - Athina Ludovica Van Gasse
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Pediatrics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Jessy Elst
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Leander De Puysseleyr
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Margaretha Antje Faber
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Christel Mertens
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Margo Maria Hagendorens
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
- Department of Pediatrics, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Chris Bridts
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Luc De Clerck
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Didier Gaston Ebo
- Department of Immunology-Allergology-Rheumatology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
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Farrell A, Judge C, Redenbaugh V, Awad H, Conlon N. Food-dependent exercise-induced reactions: lessons from a 15-year retrospective study. Ir J Med Sci 2019; 188:815-819. [PMID: 30661174 DOI: 10.1007/s11845-019-01965-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Food-dependent exercise-induced anaphylaxis (FDEIA) is a life-threatening disorder in which the signs and symptoms of anaphylaxis occur if physical exertion occurs within a few hours of exposure to a food. AIMS The aim of this study was to characterise patients diagnosed with FDEIA and related disorders. METHODS A retrospective review of electronic clinical data from 2001 to 2016 was carried out. Fifty-seven cases were identified and analysed to establish clinical features, triggering factors and sensitisation patterns. RESULTS The number of patients per annum diagnosed with FDEIA or related reactions increased from 1 in 2001 to 18 patients in 2016. Sixty-nine percent reported systemic symptoms consistent with anaphylaxis, and 31% had skin manifestations only. In 33% of cases, the level of triggering exercise was mild. Forty-four percent of patients were sensitised to the omega-5-gliadin fraction of wheat. CONCLUSIONS FDEIA is an increasingly recognised serious allergic disease. The clinical diagnosis is supported by targeted sensitisation testing and molecular-based allergy diagnostics. These tools allow implementation of effective dietary and lifestyle modifications that mitigate against future serious reactions. Given the limited access to physicians with specialist allergy training in Ireland, increased awareness of this condition amongst sports medicine specialists and general physicians is required.
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Affiliation(s)
- Aisling Farrell
- Department of Immunology, St. James's Hospital, Dublin, Ireland.
| | - Ciaran Judge
- Department of Immunology, St. James's Hospital, Dublin, Ireland
| | | | - Hanna Awad
- Department of Immunology, St. James's Hospital, Dublin, Ireland
| | - Niall Conlon
- Department of Immunology, St. James's Hospital, Dublin, Ireland
- Department of Immunology, Trinity College Dublin, Dublin, Ireland
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de Silva NR, Dasanayake WMDK, Karunatilake C, Wickramasingha GD, De Silva BD, Malavige GN. Aetiology of anaphylaxis in patients referred to an immunology clinic in Colombo, Sri Lanka. Allergy Asthma Clin Immunol 2018; 14:81. [PMID: 30455720 PMCID: PMC6225671 DOI: 10.1186/s13223-018-0295-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/24/2018] [Indexed: 01/12/2023] Open
Abstract
Background The aetiology of anaphylaxis differs according to types of foods consumed, fauna and foliage and cultural practices. Although the aetiology of anaphylaxis in Western countries are well known, the causes in South Asian countries have not been reported. We sought to determine the causes of anaphylaxis in patients referred to an immunology clinic in Colombo, Sri Lanka. Methods 238 episodes of anaphylaxis were reviewed in 188 patients who were referred and skin prick tests and in vitro tests (ImmunoCap) were carried out to assess the presence of allergen specific IgE. Clinical features and severity of anaphylaxis was also recorded along with treatment received. Results Anaphylaxis to food either following direct exposure 90/238 (37.5%) or after exercise in the form of food dependent exercise induced anaphylaxis 29/238 (12.2%) was the predominant cause of anaphylaxis. Allergy to cow's milk and red meat, after immediate exposure, accounted for 66/238 (27.7%) of instances of all episodes of anaphylaxis and 66/90 (73.33%) of anaphylaxis due to food. Vaccines accounted for 28/238 (11.8%) of instances of anaphylaxis, especially among children. Of those who developed anaphylaxis to the MMR (n = 14), 71.4% of them had specific IgE to cow's milk and 35.7% of them had specific IgE to beef. Of those who developed anaphylaxis to insect stings, 27/42 of these episodes occurred following stings of ants (family Formicidae). The predominant cause of anaphylaxis changed with the age, with food allergy being the most frequent trigger of anaphylaxis in childhood, while drug allergy and idiopathic anaphylaxis being more frequent after 30 years of age. Conclusions In this cohort, anaphylaxis to red meat appears to be the predominant cause of food induced anaphylaxis and presence of beef specific IgE and cow's milk, appears to be a predisposing factor for vaccine induced anaphylaxis.
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Affiliation(s)
| | - W M D K Dasanayake
- 1Department of Immunology, Medical Research Institute, Colombo 08, Sri Lanka
| | | | | | - B D De Silva
- 2Institute of Biochemistry Molecular Biology & Biotechnology, University of Colombo, Colombo, Sri Lanka
| | - Gathsauri Neelika Malavige
- 3Department of Microbiology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
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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.
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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.
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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]
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Wauters RH, Banks TA, Lomasney EM. Food-dependent exercise-induced anaphylaxis. BMJ Case Rep 2018; 2018:bcr-2017-222370. [PMID: 29643134 DOI: 10.1136/bcr-2017-222370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Food-dependent exercise-induced anaphylaxis (FDEIAn), first reported in 1979, is a condition defined by the consumption of a trigger food with temporally related exercise that results in an immediate hypersensitivity (type 1) reaction in the setting of the trigger food being tolerated independent of exercise and exercise being tolerated in the absence of trigger food consumption. The most common trigger food in the west is wheat and shellfish in Asia. The exact mechanism of FDEIAn is unknown, though several hypotheses exist. Cofactors such as non-steroidal anti-inflammatory drug use, alcohol consumption and others have been associated with reported cases.
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Affiliation(s)
- Robert H Wauters
- Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Taylor A Banks
- Allergy/ Immunology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Evelyn M Lomasney
- Allergy/ Immunology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
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Food-Dependent, Exercise-Induced Anaphylaxis: Diagnosis and Management in the Outpatient Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:283-288. [PMID: 28283153 DOI: 10.1016/j.jaip.2016.11.022] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/13/2016] [Accepted: 11/23/2016] [Indexed: 11/20/2022]
Abstract
Food-dependent, exercise-induced anaphylaxis is a disorder in which anaphylaxis develops most predictably during exercise, when exercise takes place within a few hours of ingesting a specific food. IgE to that food should be demonstrable. It is the combination of the food and exercise that precipitates attacks, whereas the food and exercise are each tolerated independently. Recently, it was demonstrated that exercise is not essential for the development of symptoms, and that if enough of the culprit food is ingested, often with additional augmentation factors, such as alcohol or acetylsalicylic acid, symptoms can be induced at rest in the challenge setting. Thus, food-dependent, exercise-induced anaphylaxis appears to be more correctly characterized as a food allergy syndrome in which symptoms develop only in the presence of various augmentation factors, with exercise being the primary one. However, additional factors are not usually present when the patient exercises normally, so ongoing investigation is needed into the physiologic and cellular changes that occur during exercise to facilitate food-induced anaphylaxis.
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Asaumi T, Manabe T, Yanagida N, Sato S, Ebisawa M. Wheat-Dependent Exercise-Induced Anaphylaxis. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0135-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Pravettoni V, Incorvaia C. Diagnosis of exercise-induced anaphylaxis: current insights. J Asthma Allergy 2016; 9:191-198. [PMID: 27822074 PMCID: PMC5089823 DOI: 10.2147/jaa.s109105] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Exercise-induced anaphylaxis (EIAn) is defined as the occurrence of anaphylactic symptoms (skin, respiratory, gastrointestinal, and cardiovascular symptoms) after physical activity. In about a third of cases, cofactors, such as food intake, temperature (warm or cold), and drugs (especially nonsteroidal anti-inflammatory drugs) can be identified. When the associated cofactor is food ingestion, the correct diagnosis is food-dependent EIAn (FDEIAn). The literature describes numerous reports of FDEIAn after intake of very different foods, from vegetables and nuts to meats and seafood. One of the best-characterized types of FDEIAn is that due to ω5-gliadin of wheat, though cases of FDEIAn after wheat ingestion by sensitization to wheat lipid transfer protien (LTP) are described. Some pathophysiological mechanisms underlying EIAn have been hypothesized, such as increase/alteration in gastrointestinal permeability, alteration of tissue transglutaminase promoting IgE cross-linking, enhanced expression of cytokines, redistribution of blood during physical exercise leading to altered mast-cell degranulation, and also changes in the acid–base balance. Nevertheless, until now, none of these hypotheses has been validated. The diagnosis of EIAn and FDEIAn is achieved by means of a challenge, with physical exercise alone for EIAn, and with the assumption of the suspected food followed by physical exercise for FDEIAn; in cases of doubtful results, a double-blind placebo-controlled combined food–exercise challenge should be performed. The prevention of this particular kind of anaphylaxis is the avoidance of the specific trigger, ie, physical exercise for EIAn, the assumption of the culprit food before exercise for FDEIAn, and in general the avoidance of the recognized cofactors. Patients must be supplied with an epinephrine autoinjector, as epinephrine has been clearly recognized as the first-line intervention for anaphylaxis.
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Affiliation(s)
- Valerio Pravettoni
- Clinical Allergy and Immunology Unit, Foundation IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
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