Combined effects of food and exercise on anaphylaxis

Appearance of food-dependent exercise-induced anaphylaxis as an inflammatory disease: a pediatric case report and differential diagnosis

Anaphylaxis is the most serious of all allergic reactions. Despite advances in the knowledge of anaphylaxis, its clinical manifestations continue to be under-recognized. Indeed, proper diagnosis of anaphylaxis is often missed, and the treatment is delayed. The underlying causes are still under investigation globally. Inflammation represents the cornerstone of pathophysiology of anaphylaxis. Food-dependent exercise-induced anaphylaxis (FDEIA) is a rare clinical manifestation characterized by a chronological sequence in which food ingestion followed by physical exercise leads to anaphylaxis. Its mechanisms are yet to be fully explained. We report the case of a 14-year-old Chinese male who lost consciousness while undergoing physical activity at school. Several differential diagnoses were considered such as hypovolemic shock, septic shock, anaphylactic shock or neurological adverse event. Finally, the diagnosis of FDEIA was made. This case highlights the difficulties in diagnosing FDEIA and its management, especially when the clinical history is not complete and detailed.

Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review

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.

Epidemiology of out-of-hospital cardiac arrests caused by anaphylaxis and factors associated with outcomes: an observational study

OBJECTIVES

Describe the epidemiologic features of out-of-hospital cardiac arrest (OHCA) caused by anaphylaxis and identify outcome-associated factors.

DESIGN

Observational study.

SETTING

Data from the Japanese Fire and Disaster Management Agency database.

PARTICIPANTS

A total of 292 patients from 879 057 OHCA events between 2013 and 2019 with OHCA caused by anaphylaxis and for whom prehospital resuscitation was attempted were included in the analysis.

OUTCOME MEASURES

The incidence of anaphylaxis-induced OHCA, neurologically favourable 1-month survival, defined as cerebral performance category 1 or 2, and 1-month survival.

RESULTS

The proportion of OHCAs caused by anaphylaxis was high in non-elderly and male patients from July to September and during business hours. Bystander-witnessed (adjusted OR=4.43; 95% CI 1.84 to 10.7) and emergency medical service-witnessed events (adjusted OR=3.28; 95% CI 1.21 to 8.87) were associated with higher rates of neurologically favourable 1-month survival as well as better 1-month survival. Shockable initial ECG rhythms were recorded in only 19 patients (6.5%), and prehospital defibrillation was attempted in 16 such patients (84.2%). Neither shockable initial rhythms nor prehospital defibrillation was associated with better outcomes. Patients requiring advanced airway management had poor neurological outcomes (adjusted OR=0.17; 95% CI 0.07 to 0.42) and worse 1-month survival (adjusted OR=0.28; 95% CI 0.14 to 0.58).

CONCLUSIONS

Few cases of OHCA were attributable to anaphylaxis. Witnessed OHCAs, particularly those witnessed by bystanders, were associated with better neurological outcomes. Airway complications requiring advanced airway management were likely associated with poor outcomes.

Dehydration affects exercise-induced asthma and anaphylaxis

Allergies are generally triggered by food, medication, physical exercise, stress, alcohol consumption, and dehydration. There are reports that indicate dehydration affects various kinds of physical allergies. However, there are few studies that have focused on the effects of dehydration on asthma and allergy anaphylaxis. Therefore, we analyzed the effects of dehydration on several kinds of allergy responses and exercise-induced asthma especially during the endurance exercise. PubMed was searched from April to July of 2019 using predefined search terms "dehydration," "exercise," and "allergy responses." Based on the reference search, more than one-hundred articles were identified but eighteen papers met the inclusion criteria and were analyzed for connections among exercise and dehydration, dehydration and exercise-induced asthma, and allergy responses in the main text. Results suggest that dehydration directly impairs stroke volume, cardiac output, and skin blood flow. This results in larger increases in core temperature, heart rate, and stroke volume. Additionally, exercise-induced dehydration reduces airway surface hydration, which results in an amplified brocnchoconstriction. This response to exercise occurs in those who suffer from exercise-induced asthma. Moreover, damage to the gut and impaired gut function relates to increased intestinal permeability after endurance exercise. Endurance exercise changes the immunological profiles to activate antibody-mediated immunity. Also, numerous mast cells and eosinophils were recruited, therefore isotype switching to IgE antibodies occur, this hypersensitivity activates mast cell degranulation. After degranulation, proteases, leukotrienes, prostaglandins, and histamine lead to many kinds of allergy symptoms.

A Case of Possible Monosodium Glutamate-Dependent, Exercise-Induced Anaphylaxis

A 24-year-old Asian-American male presented to the Emergency Department with his third episode of anaphylaxis in a one-year period. Based on the clinical history provided by the patient regarding each of these episodes, the trigger for the patient’s anaphylaxis appears to be the consumption of monosodium glutamate followed by physical exertion within the subsequent two to three hours. The case presented here represents a rare, but life-threatening, disorder. Identification of the triggers is important so that steps can be taken to prevent recurrence.

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.

Mite-Induced Asthma and IgE Levels to Shrimp, Mite, Tropomyosin, Arginine Kinase, and Der p 10 Are the Most Relevant Risk Factors for Challenge-Proven Shrimp Allergy

BACKGROUND

Shrimp sensitization is common in the general population, but the presence of symptoms is only moderately related to sensitization. A point still at issue is which in vivo and/or in vitro tests (food challenge, component-resolved diagnosis, house dust mite [HDM] sensitization) can help in distinguishing shrimp-allergic subjects from subjects that are sensitized but tolerant.

METHODS

The aim of this study was to evaluate the role of IgE to the different shrimp and mite allergens in distinguishing shrimp challenge-positive from challenge-negative patients. Subjects with suspected hypersensitivity reactions to shrimp, positive skin prick tests (SPTs), and/or anti-shrimp IgE were submitted to open and double-blind placebo-controlled food challenges (DBPCFC). Specific IgE to shrimp, mites, and the recombinants rPen a 1, rDer p 1, 2, and 10 were tested using ImmunoCAP-FEIA. IgE immunoblotting was performed to identify the patients' allergenic profiles.

RESULTS

In total, 13 out of 51 (25.5%) patients with reported reactions to shrimp were truly shrimp allergic (7 DBPCFC positive and 6 with documented severe reactions). These patients had significantly higher skin test wheal diameters than nonallergic patients, as well as higher levels of IgE to rPen a 1 and rDer p 10. HDM-induced asthma and the simultaneous presence of anti-nDer p 1, 2, and 10 IgE levels increased the risk of true shrimp allergy.

CONCLUSION

Food challenge tests are mandatory for the diagnosis of shrimp allergy. Tropomyosin is associated with clinical reactivity. HDM-induced asthma and anti-mite IgE are risk factors for shrimp allergy.

Can we identify patients at risk of life-threatening allergic reactions to food?

Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.

Food dependant exercise induced anaphylaxis a retrospective study from 2 allergy clinics in Colombo, Sri Lanka

The aetiology of anaphylaxis ranges from food, insect venom, drugs and various chemicals. Some individuals do not develop anaphylaxis with the offending agent unless ingestion is related temporally to physical exertion, namely food dependent exercise induced anaphylaxis (FDEIA). The foods implicated are wheat, soya, peanut, milk and sea food. A retrospective study on patients with FDEIA from two Allergy clinics in Sri Lanka from 2011 to 2015 is reported. Patients were selected who fulfilled the following criteria: clinical diagnosis of anaphylaxis according to the World Allergy Organization (WAO) criteria, where the onset of symptoms was during exertion, within 4 h of ingesting a food, the ability to eat the implicated food independent of exercise, or exercise safely, if the food was not ingested in the preceding 4 h and an in vitro (ImmunoCap serum IgE to the food) or in vivo (skin prick test) test indicating evidence of sensitivity to the food. There were 19 patients (12 males: 7 females). The ages ranged from 9 to 45 (mean 22.9, median 19 years). Eight patients (42.1%) were in the 9-16 age group. Those below 16 years had a male:female ratio of 3:5, while for those above 16 years it was 9:2. Wheat was the only food implicated in FDEIA in all patients and was confirmed by skin prick testing, or by ImmunoCap specific IgE to wheat or ω - 5 gliadin. All patients had urticaria, while 5/19 (26.3%) had angioedema of the lips. Fifteen patients (78.9%) had shortness of breath or wheezing, while 8 (42.1%) had lost consciousness. Nine patients (47. 3%) had hypotension. Fourteen (73.6%) of our patients had severe reactions, with loss of consciousness or hypotension, while 5 (26.3%) had symptoms related to the gastrointestinal tract. One patient developed anaphylaxis on two occasions following inhalation of ganja, a local cannabis derivative along with the ingestion of wheat and exertion. Wheat is the main food implicated in FDEIA in Sri Lanka. A local cannabis derivative, ganja has been implicated as a cofactor for the first time.

Exercise-induced Anaphylaxis: the Role of Cofactors

Introduction:

Anaphylaxis is a dramatic clinical emergency. It is a very severe, life-threatening generalized or systemic hypersensitivity reaction. Based on immunologic mechanism the anaphylaxis is divided in IgE, IgG, complement, or immune complexes-mediated vs non allergic anaphylaxis. There are a lot of etiologic factors of anaphylaxis, but the three principal immunologic triggers are drugs, insect stings, and foods. Regarding the clinical severity there are several proposed grading systems. The diagnosis of anaphylaxis is mainly clinical.

Discussion:

The anaphylaxis markers measured in clinical laboratories are total tryptase and histamine. There are some conditions that modulate the onset of anaphylaxis, acting as co- or augmentation factors, which significantly lower the allergen dose necessary for triggering anaphylaxis. The well-documented cofactors of anaphylaxis are physical exercise, alcohol consumption, some foods, co-administration of nonsteroidal anti-inflammatory drugs (NSAID), and concomitant infectious diseases. Development of anaphylaxis depends on the sensitization pattern, the proportion of the involved immunoglobulin classes, characteristics of the allergen, the proportion of the involved immunoglobulin classes, the avidity and affinity of immunoglobulins to bind an allergen, the route of allergen application, and, last but not least, the presence of cofactors of anaphylaxis.

Conclusion:

Anaphylaxis remains a continuous challenge for the diagnosis and treatment. The adequate management of anaphylaxis requires rapid diagnosis, implementation of primary and secondary prevention measures, and immediate administration of subcutaneous epinephrine.