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Kohno K, Matsuo H, Takahashi H, Niihara H, Chinuki Y, Kaneko S, Honjoh T, Horikawa T, Mihara S, Morita E. Serum gliadin monitoring extracts patients with false negative results in challenge tests for the diagnosis of wheat-dependent exercise-induced anaphylaxis. Allergol Int 2013; 62:229-38. [PMID: 23612492 DOI: 10.2332/allergolint.12-oa-0495] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 12/20/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Challenge testing with wheat plus exercise and/or aspirin is a gold standard for the diagnosis of wheat-dependent exercise-induced anaphylaxis (WDEIA); however, the test may often yield false-negative results. Our previous study suggested that an increase in serum wheat gliadin levels is required to induce allergic symptoms in patients with WDEIA. Based on this knowledge, we sought to extract the patients with false negative results in the challenge tests of WDEIA. METHODS Thirty-six patients with suspected WDEIA were enrolled. First, group categorizations-Group I, challenge tests were positive; Group II, challenge tests were negative and serum gliadin were undetectable; Group III, challenge tests were negative and serum gliadin were detectable-were given according to the results of wheat plus exercise and/or aspirin challenge testing and serum gliadin levels. Second, diagnoses were made using retests and/or dietary management in Group II and III. RESULTS Positive results for wheat plus exercise and/or aspirin challenge tests gave a diagnosis of definite WDEIA in 17 of 36 patients (Group I). Of the remaining 19 challenge negative patients, serum gliadin was undetectable in ten patients (Group II). Of the ten patients (Group II), three of them were diagnosed as definite WDEIA by retesting and six of them were diagnosed as probable WDEIA using a wheat elimination diet, whereas one patient was non-WDEIA. In the rest of the nine challenge negative patients, serum gliadin was detectable (Group III). No allergic episodes with a normal diet provided a diagnosis of non-WDEIA in seven of the nine patients, whereas the remaining two patients were probable WDEIA or had another food allergy because of repeated episodes. CONCLUSIONS Our study revealed that serum gliadin monitoring during challenge testing is useful.
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Affiliation(s)
- Kunie Kohno
- Department of Dermatology, Faculty of Medicine, Shimane University, Shimane, Japan. −u.ac.jp
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Romano A, Scala E, Rumi G, Gaeta F, Caruso C, Alonzi C, Maggioletti M, Ferrara R, Palazzo P, Palmieri V, Zeppilli P, Mari A. Lipid transfer proteins: the most frequent sensitizer in Italian subjects with food-dependent exercise-induced anaphylaxis. Clin Exp Allergy 2013; 42:1643-53. [PMID: 23106665 DOI: 10.1111/cea.12011] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Specific food-dependent exercise-induced anaphylaxis (S-FDEIAn) is a distinct form of food allergy in which symptoms are elicited by exercise performed after ingesting food to which the patient has become sensitised. Non-specific FDEIAn (NS-FDEIAn) is a syndrome provoked by exercise performed after ingesting any food. OBJECTIVE We sought to identify the culprit allergenic molecules in patients with FDEIAn, combining 'classic' allergy testing with an allergenic molecule-based microarray approach for IgE detection. METHODS All subjects were evaluated who reported at least one episode of anaphylaxis in association with physical exercise performed within 4 h after a meal. We performed skin prick tests (SPT) with commercial food extracts, prick plus prick tests (P + P) with fresh foods (P + P), and serum specific IgE assays by means of both the ImmunoCAP (CAP) and the ISAC 89 microarray system (ISAC). RESULTS Among our 82 FDEIAn patients, the most frequent suspected foods were tomato, cereals, and peanut. SPT, P + P, and CAP displayed different degrees of sensitivity. Each test disclosed some positivities not discovered by others. Seventy-nine subjects were positive to at least one food (49 to more than 20), whereas three were negative. All suspected foods were positive to at least one of SPT, P + P, and CAP. When tested using the ISAC, 64 (78%) subjects were positive to Pru p 3 [peach lipid transfer protein (LTP)], 13 were positive to other food allergen molecules, and five displayed negative results to all food allergenic molecules. Overall, 79 patients probably had S-FDEIAn and the other 3 NS-FDEIAn. CONCLUSIONS Multiple food hypersensitivity represents a clinical hallmark of a large percentage of FDEIAn patients. The very high prevalence of IgE to the LTP suggests a role of this allergen group in causing S-FDEIAn.
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Affiliation(s)
- A Romano
- Allergy Unit, Complesso Integrato Columbus, Rome, Italy.
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Abstract
Recently, the National Institute of Allergy and Infectious Diseases sought to establish consistency in definitions, diagnostic criteria, and management practices concerning food allergies (FAs). This review aimed to summarize and highlight the relevant findings of these guidelines for the emergency department provider, as pediatric patients often present to the emergency department with FAs or other disorders mimicking FAs.
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Rance K, Goldberg P. Food Allergy in Clinical Practice. J Nurse Pract 2013. [DOI: 10.1016/j.nurpra.2013.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Exercise-induced anaphylaxis: a case report and review of the diagnosis and treatment of a rare but potentially life-threatening syndrome. Case Rep Med 2013; 2013:610726. [PMID: 23585764 PMCID: PMC3622308 DOI: 10.1155/2013/610726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 03/07/2013] [Indexed: 12/03/2022] Open
Abstract
A 24-year-old male Marine with an uncomplicated medical history and a long history of strenuous, daily exercise presented to the emergency department after experiencing anaphylactic shock while running. Symptoms resolved following administration of intramuscular diphenhydramine, ranitidine, intravenous methylprednisolone, and intravenous fluids. On followup in the allergy clinic, a meticulous clinical history was obtained which elucidated a picture consistent with exercise-induced anaphylaxis. He had experienced diffuse pruritus and urticaria while exercising on multiple occasions over the last three years. His symptoms would usually increase as exercise continued. Prior to the first episode, he regularly exercised without symptoms. Exercise-induced anaphylaxis is a rare but potentially life-threatening syndrome that requires a careful clinical history and is a diagnosis of exclusion. Treatment is primarily exercise avoidance. Prophylactic mediations are inconsistently effective but are empirically used. Successful treatment with omalizumab was recently reported in a case of refractory exercise-induced anaphylaxis.
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Im JH, Kwon HY, Ye YM, Park HS, Kim TB, Choi GS, Kim JH, Jang GC, Kim MK, Hur GY, Koh YI, Sohn SW, Kim CW. Food-dependent exercise-induced anaphylaxis in Korea: a multicenter retrospective case study. ALLERGY ASTHMA & RESPIRATORY DISEASE 2013. [DOI: 10.4168/aard.2013.1.3.203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jae Hyoung Im
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Hea Yoon Kwon
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
| | - Young-Min Ye
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Internal Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Tae-Bum Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Soon Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Mi Kyung Kim
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gyu-Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young-Il Koh
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Seong-Wook Sohn
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Cheol-Woo Kim
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea
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Bonini M, Marcomini L, Gramiccioni C, Tranquilli C, Melioli G, Canonica GW, Bonini S. Microarray evaluation of specific IgE to allergen components in elite athletes. Allergy 2012; 67:1557-64. [PMID: 23033844 DOI: 10.1111/all.12029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allergic sensitization and diseases have been reported to have a very high and increasing prevalence in elite athletes. Over 80% of allergic athletes are poly-sensitized. OBJECTIVE This study aims at evaluating the potential diagnostic added value of a microarray technology (ImmunoCAP ISAC, Phadia AB [at present Thermo Fisher Scientific] Uppsala, Sweden which detects IgE antibodies to specific or cross-reacting allergen components. METHODS Seventy-two poly-sensitized athletes according to skin prick test (SPT) with different allergic phenotypes (asthma n = 19; rhino-conjunctivitis n = 20; food allergy and/or oral allergy syndrome n = 13; no clinical symptoms n = 20) and two different control populations (20 poly-sensitized sedentary subjects with respiratory allergy and 20 healthy athletes with negative SPT) were studied for detecting specific IgE (sIgE) both to allergen extracts (ImmunoCAPsIgE) and to allergen components (ImmunoCAP ISAC). RESULTS ImmunoCAP ISAC detected the presence of sIgE in 90% of poly-sensitized athletes--in 96% with symptoms and in 75% without symptoms--and in 100% of allergic controls. The pattern of positivity towards the 103 components tested differed from subject to subject, even in those with the same sensitization to allergen extract SPT or sIgE. Based on the ISAC results, poly-sensitized athletes were classified into the following prototypical patterns, differently represented in the clinical phenotypes studied (P = 0.03): (1) One single predominant specific allergen positivity; (2) sIgE to two or more non-cross-reacting allergens; (3) sIgE to cross-reacting allergens; and (4) sIgE to components potentially responsible for severe allergic reactions. CONCLUSIONS The ImmunoCAP ISAC represents a useful additional tool for diagnosis and management of poly-sensitized athletes.
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Affiliation(s)
| | - L. Marcomini
- Department of Experimental Medicine, Central Laboratory; G. Gaslini Insitute; Genoa; Italy
| | - C. Gramiccioni
- Institute of Translational Pharmacology; Italian National Research Council; Rome; Italy
| | - C. Tranquilli
- Institute of Sport Medicine and Sciences; Italian National Olympic Committee; Rome; Italy
| | - G. Melioli
- Department of Experimental Medicine, Central Laboratory; G. Gaslini Insitute; Genoa; Italy
| | - G. W. Canonica
- Department of Medicine, Allergy and Respiratory Diseases; University of Genoa; Genoa; Italy
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Goldflam K, Silvers CT. Exercise-induced Anaphylaxis as a Cause of Syncope. J Emerg Med 2012; 43:651-4. [DOI: 10.1016/j.jemermed.2010.05.070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2009] [Revised: 04/01/2010] [Accepted: 05/18/2010] [Indexed: 12/01/2022]
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Abstract
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.
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Affiliation(s)
- Carlotta Povesi Dascola
- Clinica Pediatrica, Dipartimento di Medicina Clinica e Sperimentale, Azienda Ospedaliera-Universitaria di Parma, Università degli Studi di Parma, Via Gramsci 14, Parma, Italy
| | - Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina Clinica e Sperimentale, Azienda Ospedaliera-Universitaria di Parma, Università degli Studi di Parma, Via Gramsci 14, Parma, Italy
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Tuckova L, Sanchez D, Tlaskalova-Hogenova H, Panzner P. Wheat-dependent exercise-induced anaphylaxis: Pros and cons of recombinant ω-5gliadin and glutenins, or their epitope peptides, in diagnosis. Clin Exp Allergy 2012; 42:1146-9. [DOI: 10.1111/j.1365-2222.2012.04050.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- L. Tuckova
- Department of Immunology and Gnotobiology; Institute of Microbiology, v.v.i; Academy of Sciences of the Czech Republic
| | - D. Sanchez
- Department of Immunology and Gnotobiology; Institute of Microbiology, v.v.i; Academy of Sciences of the Czech Republic
| | - H. Tlaskalova-Hogenova
- Department of Immunology and Gnotobiology; Institute of Microbiology, v.v.i; Academy of Sciences of the Czech Republic
| | - P. Panzner
- Department of Immunology and Allergology; Medical Faculty in Pilsen; Charles University; Czech Republic
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Burks AW, Tang M, Sicherer S, Muraro A, Eigenmann PA, Ebisawa M, Fiocchi A, Chiang W, Beyer K, Wood R, Hourihane J, Jones SM, Lack G, Sampson HA. ICON: food allergy. J Allergy Clin Immunol 2012; 129:906-20. [PMID: 22365653 DOI: 10.1016/j.jaci.2012.02.001] [Citation(s) in RCA: 374] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 02/02/2012] [Indexed: 12/11/2022]
Abstract
Food allergies can result in life-threatening reactions and diminish quality of life. In the last several decades, the prevalence of food allergies has increased in several regions throughout the world. Although more than 170 foods have been identified as being potentially allergenic, a minority of these foods cause the majority of reactions, and common food allergens vary between geographic regions. Treatment of food allergy involves strict avoidance of the trigger food. Medications manage symptoms of disease, but currently, there is no cure for food allergy. In light of the increasing burden of allergic diseases, the American Academy of Allergy, Asthma & Immunology; European Academy of Allergy and Clinical Immunology; World Allergy Organization; and American College of Allergy, Asthma & Immunology have come together to increase the communication of information about allergies and asthma at a global level. Within the framework of this collaboration, termed the International Collaboration in Asthma, Allergy and Immunology, a series of consensus documents called International Consensus ON (ICON) are being developed to serve as an important resource and support physicians in managing different allergic diseases. An author group was formed to describe the natural history, prevalence, diagnosis, and treatment of food allergies in the context of the global community.
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Affiliation(s)
- A Wesley Burks
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA.
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Trcka J, Schäd SG, Scheurer S, Conti A, Vieths S, Gross G, Trautmann A. Rice-induced anaphylaxis: IgE-mediated allergy against a 56-kDa glycoprotein. Int Arch Allergy Immunol 2011; 158:9-17. [PMID: 22205234 DOI: 10.1159/000330641] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 06/20/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although rice (Oryza sativa) is one of the most common cereals produced and consumed around the world, there have been only a few reports on immediate hypersensitivity reactions after ingestion of rice. Few clinical studies on rice allergy in Asia have been reported concerning rhinitis, asthma and atopic dermatitis. In this case study, we identify allergens presumably responsible for anaphylaxis after ingestion of rice in a German patient. METHODS Prick-to-prick tests, determination of specific IgE and the basophil activation test (BAT) were performed to confirm IgE-mediated allergy. IgE reactivity was further analyzed by immunoblotting of protein extracts from cooked commercial rice products. Rice allergens were purified, subjected to N-terminal sequencing and characterized by IgE binding and IgE inhibition assays using additional sera from 8 subjects with sensitization to rice and/or a history of hypersensitivity symptoms after rice ingestion. RESULTS Prick-to-prick tests were positive to raw and cooked rice (basmati rice and long-grain rice) and preparations of different rice extracts. Specific IgE against rice (f9) was 1.87 kU(A)/l. The BAT showed specific IgE-mediated activation of basophils after stimulation with rice extracts. Four IgE-reactive rice proteins with an apparent molecular weight of 49, 52, 56 and 98 kDa were identified. Interestingly, only binding to the 56-kDa glycoprotein was at least partially independent from cross-reactive carbohydrate determinants (CCD), whereas IgE binding to the other rice proteins was completely inhibited by pre-incubation with the CCD MUXF derived from bromelain. CONCLUSIONS Yet unidentified high-molecular-weight allergens from rice seeds, predominantly a 56-kDa glycoprotein, seem to be responsible for anaphylaxis after consumption of rice in a German patient.
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Affiliation(s)
- Jiri Trcka
- Department of Dermatology and Venereology, University of Rostock, Rostock, Germany.
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64
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Skypala I. Adverse Food Reactions—An Emerging Issue for Adults. ACTA ACUST UNITED AC 2011; 111:1877-91. [DOI: 10.1016/j.jada.2011.09.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 05/20/2011] [Indexed: 01/03/2023]
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Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa'ad A, Sampson HA. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics 2011; 128:955-65. [PMID: 21987705 PMCID: PMC3208961 DOI: 10.1542/peds.2011-0539] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Data from many studies have suggested a rise in the prevalence of food allergies during the past 10 to 20 years. Currently, no curative treatments for food allergy exist, and there are no effective means of preventing the disease. Management of food allergy involves strict avoidance of the allergen in the patient's diet and treatment of symptoms as they arise. Because diagnosis and management of the disease can vary between clinical practice settings, the National Institute of Allergy and Infectious Diseases (NIAID) sponsored development of clinical guidelines for the diagnosis and management of food allergy. The guidelines establish consensus and consistency in definitions, diagnostic criteria, and management practices. They also provide concise recommendations on how to diagnose and manage food allergy and treat acute food allergy reactions. The original guidelines encompass practices relevant to patients of all ages, but food allergy presents unique and specific concerns for infants, children, and teenagers. To focus on those concerns, we describe here the guidelines most pertinent to the pediatric population.
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Affiliation(s)
- A. Wesley Burks
- Division of Allergy and Immunology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Stacie M. Jones
- Division of Allergy and Immunology, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | - Joshua A. Boyce
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Scott H. Sicherer
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York
| | - Robert A. Wood
- Division of Allergy and Immunology, Department of Pediatrics, Johns Hopkins University Medical Center, Baltimore, Maryland; and
| | - Amal Assa'ad
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Hugh A. Sampson
- Elliot and Roslyn Jaffe Food Allergy Institute, Division of Allergy and Immunology, Department of Pediatrics, Mount Sinai School of Medicine, New York, New York
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Hompes S, Köhli A, Nemat K, Scherer K, Lange L, Rueff F, Rietschel E, Reese T, Szepfalusi Z, Schwerk N, Beyer K, Hawranek T, Niggemann B, Worm M. Provoking allergens and treatment of anaphylaxis in children and adolescents--data from the anaphylaxis registry of German-speaking countries. Pediatr Allergy Immunol 2011; 22:568-74. [PMID: 21435004 DOI: 10.1111/j.1399-3038.2011.01154.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Anaphylaxis is the most severe reaction of an IgE-mediated hypersensitivity. Data about affected patients may help to improve our knowledge of anaphylaxis and its medical care. We analysed data from the anaphylaxis registry of German speaking countries with regard to the provoking allergens and treatment modalities of anaphylaxis in children and adolescents. Inclusion criteria were severe systemic allergic reactions with concomitant pulmonary and/or cardiovascular symptoms. The data are collected by a password-controlled online-questionnaire. For this analysis, data of 197 reported anaphylactic reactions from children and adolescents registered between 2006 and 2009 were included. The data show that within the registered cases the most frequently affected organ systems for children and adolescents were the skin (89%) and the respiratory tract (87%) followed by symptoms of the cardiovascular system (47%) and the gastrointestinal tract (43%). The most frequent elicitors were food allergens accounting for 58% of cases, followed by insect venom (24%) and drugs (8%). The most frequent food allergens were peanuts followed by tree nuts and animal related food products. In 18% aggravating factors such as physical exercise were noted by the clinicians. 26% of the analysed patients had experienced more than one reaction. The data regarding the emergency treatment show that antihistamines (87%) and corticosteroids (85%) were often used but that adrenaline was rarely used (22% of the registered cases). Taken together these data show that the analysis of anaphylaxis by registration of affected individuals can provide data about provoking allergens and treatment measures but also suggest the impact of aggravating factors on anaphylactic reactions. The under-represented usage of adrenaline indicates the need of educational measures for patients and their physicians.
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Affiliation(s)
- Stephanie Hompes
- Department of Dermatology and Allergy, University Hospital Charité Berlin, Germany
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Gil-Díaz A, Delgado-Martínez J, Suárez-Ortega S. Case 9-2011: A man with flushing and hypotension. N Engl J Med 2011; 365:93-4; author reply 94. [PMID: 21732851 DOI: 10.1056/nejmc1105149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, Plaut M, Cooper SF, Fenton MJ, Arshad SH, Bahna SL, Beck LA, Byrd-Bredbenner C, Camargo CA, Eichenfield L, Furuta GT, Hanifin JM, Jones C, Kraft M, Levy BD, Lieberman P, Luccioli S, McCall KM, Schneider LC, Simon RA, Simons FER, Teach SJ, Yawn BP, Schwaninger JM. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2011; 126:1105-18. [PMID: 21134576 DOI: 10.1016/j.jaci.2010.10.008] [Citation(s) in RCA: 1001] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 10/13/2010] [Indexed: 12/11/2022]
Abstract
Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.
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Affiliation(s)
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- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA
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Barg W, Medrala W, Wolanczyk-Medrala A. Exercise-induced anaphylaxis: an update on diagnosis and treatment. Curr Allergy Asthma Rep 2011; 11:45-51. [PMID: 20922508 PMCID: PMC3020292 DOI: 10.1007/s11882-010-0150-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Exercise-induced anaphylaxis (EIA) and food-dependent, exercise-induced anaphylaxis (FDEIA) are rare but potentially life-threatening clinical syndromes in which association with exercise is crucial. The range of triggering physical activities is broad, including as mild an effort as a stroll. EIA is not fully repeatable (ie, the same exercise may not always result in anaphylaxis in a given patient). In FDEIA, the combined ingestion of sensitizing food and exercise is necessary to precipitate symptoms. Clinical features and management do not differ significantly from other types of anaphylaxis. The pathophysiology of EIA and FDEIA is not fully understood. Different hypotheses concerning the possible influence of exercise on the development of anaphylactic symptoms are taken into consideration. These include increased gastrointestinal permeability, blood flow redistribution, and most likely increased osmolality. This article also describes current diagnostic and therapeutic possibilities, including changes in lifestyle and preventive properties of antiallergic drugs as well as acute treatment of these dangerous syndromes.
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Affiliation(s)
- Wojciech Barg
- Department of Physiology, Medical University of Wroclaw, Wroclaw, Poland
| | - Wojciech Medrala
- Department of Internal Diseases, Geriatrics, and Allergology, Medical University of Wroclaw, 57 Traugutta Street, 50-417 Wroclaw, Poland
| | - Anna Wolanczyk-Medrala
- Department of Internal Diseases, Geriatrics, and Allergology, Medical University of Wroclaw, 57 Traugutta Street, 50-417 Wroclaw, Poland
- Department of Clinical Research, Medical School of Legnica, Legnica, Poland
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Tanaka M, Nagano T, Yano H, Haruma K, Kato Y. Exercise-Independent Wheat-Induced Anaphylaxis Caused by ω-5 Gliadin in Mice. Int Arch Allergy Immunol 2011; 156:434-42. [DOI: 10.1159/000324469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 01/14/2011] [Indexed: 11/19/2022] Open
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71
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Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA, Plaut M, Cooper SF, Fenton MJ, Arshad SH, Bahna SL, Beck LA, Byrd-Bredbenner C, Camargo CA, Eichenfield L, Furuta GT, Hanifin JM, Jones C, Kraft M, Levy BD, Lieberman P, Luccioli S, McCall KM, Schneider LC, Simon RA, Simons FER, Teach SJ, Yawn BP, Schwaninger JM. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. J Allergy Clin Immunol 2010; 126:S1-58. [PMID: 21134576 PMCID: PMC4241964 DOI: 10.1016/j.jaci.2010.10.007] [Citation(s) in RCA: 534] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 10/13/2010] [Indexed: 12/14/2022]
Abstract
Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.
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72
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Lieberman P, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DBK, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477-80.e1-42. [PMID: 20692689 DOI: 10.1016/j.jaci.2010.06.022] [Citation(s) in RCA: 455] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 04/27/2010] [Accepted: 06/08/2010] [Indexed: 11/19/2022]
Abstract
These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.
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Affiliation(s)
- Phillip Lieberman
- JointCouncil of Allergy, Asthma&Immunology, 50NBrockway St, #3-3, Palatine, IL 60067, USA.
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73
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Beaudouin E. Anaphylaxie alimentaire induite par l’effort : épidémiologie et aspects cliniques. REVUE FRANCAISE D ALLERGOLOGIE 2010. [DOI: 10.1016/j.reval.2010.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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74
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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.
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Affiliation(s)
- Eishin Morita
- Department of Dermatology, Shimane University Faculty of Medicine, Shimane, Japan.
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75
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Lee HB, Ahn IS, Choi JH, Park CW, Lee CH. A case of wheat-dependent exercise-induced anaphylaxis. Ann Dermatol 2009; 21:447-9. [PMID: 20523846 DOI: 10.5021/ad.2009.21.4.447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Revised: 05/06/2009] [Accepted: 06/16/2009] [Indexed: 11/08/2022] Open
Abstract
Foods are recognized as a common cause of urticaria; however, the role of food is considered to be more important in acute not chronic urticaria. Wheat is a basic ingredient found in many common foods. Food allergy to wheat is primarily described in children in the form of atopic dermatitis. It is rare in adults; where it is mainly reported in exercise-induced anaphylaxis. We report a case of wheat dependent exercise-induced anaphylaxis that occurred in a 54-year-old Korean woman.
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Affiliation(s)
- Hee Bong Lee
- Department of Dermatology, College of Medicine, Hallym University, Seoul, Korea
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76
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Davis CM. Food allergies: clinical manifestations, diagnosis, and management. Curr Probl Pediatr Adolesc Health Care 2009; 39:236-54. [PMID: 19913754 DOI: 10.1016/j.cppeds.2009.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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77
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Teo SL, Gerez IFA, Ang G, Shek LP. Food-dependent Exercise-induced Anaphylaxis – A Review of 5 Cases. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2009. [DOI: 10.47102/annals-acadmedsg.v38n10p905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Introduction: Food-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon and under-recognised syndrome that clinicians may not consider in a patient presenting with ana- phylaxis.
Clinical Picture: We describe here 5 patients aged 9 to 20 years old who presented at a local tertiary hospital over a 2-year period from August 2006 to July 2008. All presented with urticaria, 4 were hypotensive, 2 had angioedema and another 2 had dyspnoea. The symptoms occurred between 15 and 150 minutes (mean, 81) after exercising and consuming various food. All had consumed shellfish. All patients were admitted with the diagnosis of anaphylaxis of undefined aetiology. Diagnosis of FDEIA was only reached upon referral to an allergist.
Treat- ment and Outcome: Patients were treated with standard medicines for anaphylaxis including adrenaline, antihistamines, steroids and fluid flushes. Symptoms resolved in 2 to 3 days with no further episodes. At discharge, patients were prescribed epinephrine auto-injectors and given written anaphylaxis management plans.
Conclusions: More public awareness and strategies to ensure accurate diagnosis and management of this condition are necessary.
Key words: Anaphylaxis, Epinephrine, Exercise, Food
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Affiliation(s)
| | | | - Gerez Ang
- National University of Singapore, Singapore
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78
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Food anaphylaxis. Anal Bioanal Chem 2009; 395:17-23. [PMID: 19618167 DOI: 10.1007/s00216-009-2939-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Revised: 06/17/2009] [Accepted: 06/25/2009] [Indexed: 10/20/2022]
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79
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Choi JH, Lee HB, Ahn IS, Park CW, Lee CH. Wheat-dependent, Exercise-induced Anaphylaxis: A Successful Case of Prevention with Ketotifen. Ann Dermatol 2009; 21:203-5. [PMID: 20523788 DOI: 10.5021/ad.2009.21.2.203] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 12/15/2008] [Indexed: 11/08/2022] Open
Abstract
Food-dependent, exercise-induced anaphylaxis (FDEIA) is the triggering of anaphylaxis after ingestion of certain foods when followed by physical exercise. Symptoms vary from the typical generalized urticaria to severe allergic reactions. We report the case of a 20-year-old woman who had a 7-year history of recurrent wheals and dyspnea after ingesting several kinds of food (wheat, pork, and beef) along with physical exercise. Based on a provocation test, she was diagnosed with wheat-dependent, exercise-induced anaphylaxis. She was instructed to take 2 mg of ketotifen 2 hours before ingestion of wheat to prevent the symptoms, and subsequently the provocation test did not elicit wheals. We therefore prescribed ketotifen (1 mg twice a day). She has not had recurrent wheals or dyspnea for 6 months. We herein report an interesting case of wheat-dependent, exercise-induced anaphylaxis with successful prevention by ketotifen.
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Affiliation(s)
- Ji Hoon Choi
- Department of Dermatology, College of Medicine, Hallym University, Seoul, Korea
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80
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Miller CWT, Guha B, Krishnaswamy G. Exercise-induced anaphylaxis: a serious but preventable disorder. PHYSICIAN SPORTSMED 2008; 36:87-94. [PMID: 20048476 DOI: 10.3810/psm.2008.12.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Described for the first time approximately 30 years ago, exercise-induced anaphylaxis is a rare disorder characterized by development of a severe allergic response occurring after mild-to-strenuous physical activity. This disorder is especially important to recognize with the recent increase in physical activity and health fitness fads. A number of predisposing factors (eg, prior ingestion of particular food groups) linked to exercise-induced anaphylaxis has been outlined over the years. Mechanisms governing the condition are still being unveiled, and it is likely that one mechanism involves mast cell degranulation and inflammatory mediator generation resulting from the biochemical effects of exercise, sometimes in the presence of an ingested allergen such that wheat or shell fish. Clinical manifestations usually occur after around 10 minutes of exercise, and follow a specific sequence, starting with pruritis and widespread urticarial lesions, evolving into a more typical anaphylactic picture with respiratory distress and vascular collapse. Fatality is exceedingly rare, with only one documented case in the literature. There is an overlap of symptoms with other syndromes (such as systemic mastocytosis and cholinergic urticaria), and these should be remembered when establishing a differential. Treatment of exercise-induced anaphylaxis consists of immediate stabilization geared toward the anaphylactic response with epinephrine and anti histamines. The patient needs to be educated on preventive measures and equipped with an epinephrine autoinjector in the event of an emergency. Exercise-induced anaphylaxis remains a potentially serious disorder, and the health care provider should be aware of its clinical features and effective management strategies. KEYWORDS anaphylaxis; allergy; exercise; hypotension; urticaria; asthma.
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Affiliation(s)
- Christopher W T Miller
- Department of Internal Medicine James H. Quillen VA Medical Center and the Quillen College of Medicine, East Tennessee State University, Johnson City, TN, 37614-1700, USA
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81
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Abstract
A 47-year-old man presented to our hospital with collapse secondary to a subarachnoid hemorrhage. A careful history taking revealed symptoms of anaphylaxis before his collapse. This case illustrates an unusual cause of subarachnoid hemorrhage.
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82
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Schwartz LB, Delgado L, Craig T, Bonini S, Carlsen KH, Casale TB, Del Giacco S, Drobnic F, van Wijk RG, Ferrer M, Haahtela T, Henderson WR, Israel E, Lötvall J, Moreira A, Papadopoulos NG, Randolph CC, Romano A, Weiler JM. Exercise-induced hypersensitivity syndromes in recreational and competitive athletes: a PRACTALL consensus report (what the general practitioner should know about sports and allergy). Allergy 2008; 63:953-61. [PMID: 18691297 DOI: 10.1111/j.1398-9995.2008.01802.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- L B Schwartz
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
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83
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84
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Wong CG, Mace SR. Food-dependent exercise-induced anaphylaxis: a case related to chickpea ingestion and review. Allergy Asthma Clin Immunol 2007; 3:134-7. [PMID: 20525119 PMCID: PMC2873610 DOI: 10.1186/1710-1492-3-4-134] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
: 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.
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Affiliation(s)
- Chet G Wong
- School of Medicine, Queen's University, Kingston, ON
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85
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Abstract
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.
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Affiliation(s)
- George Du Toit
- Children's Allergy Service, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK.
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86
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Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G, Moneret-Vautrin A, Niggemann B, Rancé F. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy 2007; 62:857-71. [PMID: 17590200 DOI: 10.1111/j.1398-9995.2007.01421.x] [Citation(s) in RCA: 327] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.
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Affiliation(s)
- A Muraro
- Centre for Food Allergy Diagnosis and Treatment Veneto Region, Department of Pediatrics, University of Padua, Padua, Italy
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87
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Pourpak Z, Ghojezadeh L, Mansouri M, Mozaffari H, Farhoudi A. Wheat anaphylaxis in children. Immunol Invest 2007; 36:175-82. [PMID: 17365018 DOI: 10.1080/08820130600941211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Food anaphylaxis is now the leading known cause of anaphylactic reactions treated in emergency departments, and wheat is one of the most common causes of anaphylaxis. Wheat is an important source of food worldwide. Wheat anaphylaxis is increasingly observed in our clinic. The purpose of this study was to describe the clinical features of wheat-induced anaphylaxis in 19 children for better elucidation of this disease. Children with severe reactions after ingestion of small amounts of wheat were referred to our clinic during a 4-year period. A detailed clinical history was recorded for each of the patients and a skin prick test was performed with wheat allergen extracts. The wheat-specific IgE and total IgE were measured. Grading of anaphylaxis episodes was performed according to a specific grading system. We identified 36 episodes of wheat anaphylaxis in 19 patients. All of the first attacks of wheat anaphylaxis occurred in the first-time ingestion. The most frequent manifestations of the reactions were skin and respiratory symptoms. In this study 78.9% of reactions were moderate and 21.1% of them were severe. All of our patients had positive skin prick tests to wheat. Mean total IgE level was 853.4 +/- 455.27 IU/ml, and mean wheat-specific IgE was 70 +/- 14.61 Ucs/ml. We conclude that wheat-induced anaphylaxis is a disease that is sufficiently severe, and. prevention of first wheat-induced anaphylaxis episodes is almost impossible. It would, however, probably be good practice to educate physicians to recognize the common clinical manifestations of this disease for early management.
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Affiliation(s)
- Zahra Pourpak
- Immunology, Asthma and Allergy Research Institute, Tehran University of Medical Sciences, Children Medical Center, Tehran, Iran.
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88
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Morita E, Kunie K, Matsuo H. Food-dependent exercise-induced anaphylaxis. J Dermatol Sci 2007; 47:109-17. [PMID: 17507204 DOI: 10.1016/j.jdermsci.2007.03.004] [Citation(s) in RCA: 147] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 03/07/2007] [Indexed: 11/29/2022]
Abstract
Food-dependent exercise induced anaphylaxis (FDEIA) is a distinct form of food allergy induced by physical exercise. Symptoms are typically generalized urticaria and severe allergic reactions such as shock or hypotension. Whereas various food items are responsible for the development of FDEIA, wheat is reported to be the allergen with the highest frequency in Japan. Recently aspirin has been known to be an additional exacerbating factor. Skin tests and in vitro serum food-specific IgE assays are currently used, however their sensitivity and specificity are not always satisfactory. A challenge test consisting of ingestion of assumed food followed by intense physical exercise is the only reliable method to determine the causative food and to diagnose the disease. The challenge test is not always safe because in some cases the test induces an anaphylactic shock. So a reliable in vitro diagnostic method is necessary for the patients with FDEIA. We revealed that wheat omega-5 gliadin and high molecular weight glutenin subunit are major allergens in wheat-dependent exercise-induced anaphylaxis (WDEIA). A simultaneous detection of specific IgE to epitope sequences of both omega-5 gliadin and high molecular weight glutenin is found to achieve higher sensitivity and specificity compared with the in vitro serum food-specific IgE assays currently used for diagnosis of WDEIA. On the other hand, immunoreactive gliadins appeared in the sera of patients during the provocation test with both wheat-exercise and wheat-aspirin challenges in parallel with allergic symptoms. These findings suggest that FDEIA is IgE-mediated hypersensitivity reaction to foods and both exercise and aspirin facilitate allergen absorption from the gastrointestinal tract.
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Affiliation(s)
- Eishin Morita
- Department of Dermatology, Shimane University School of Medicine, 89-1 Enya, Izumo 693-8501, Japan.
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89
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Kumar R, Srivastava P, Kumari D, Fakhr H, Sridhara S, Arora N, Gaur SN, Singh BP. Rice (Oryza sativa) allergy in rhinitis and asthma patients: a clinico-immunological study. Immunobiology 2006; 212:141-7. [PMID: 17336834 DOI: 10.1016/j.imbio.2006.11.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 11/09/2006] [Accepted: 11/10/2006] [Indexed: 10/23/2022]
Abstract
Sensitization to foods varies in different countries reflecting a possible interaction of genetic factors, cultural and dietary habits. Rice is a major food consumed world wide and needs evaluation for IgE mediated reactions. The present study was carried out to identify rice allergy in patients of rhinitis and asthma and identify the allergenic proteins in raw and cooked rice. Of 1200 patients screened using standard questionnaire, 165 presented with history of rice allergy. Of these, 20 (12.1%) patients demonstrated marked positive skin prick test (SPT) and 13 showed significantly raised specific IgE to rice compared to normal controls. Double blind placebo controlled food challenge (DBPCFC) confirmed rice allergy in 6/10 patients. Immunoblot with hypersensitive individual patients' sera showed 14-16, 33, 56 and 60 kDa proteins as major IgE-binding components in rice. Boiled rice retained four IgE reactive proteins of 16, 23, 33 and 53 kDa. In summary, IgE-mediated rice allergy affects 0.8% [(0.42-1.58) at 95% CI] of asthma and rhinitis cases. The subjects with severe SPT reactions (4 mm or above) and specific IgE, 6.9 ng/ml to rice demonstrated positive blinded food challenge with clinical symptoms.
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Affiliation(s)
- Raj Kumar
- Vallabhbhai Patel Chest Institute, Delhi University, Delhi, India
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90
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Abstract
The diagnosis of food allergy requires obtaining a detailed medical history and consideration of differential diagnosis. The offending food(s) may be identified by the medical history, trials of elimination diets, SPT, food-specific IgE measurement, or some combination. However, the reliability of these methods is usually suboptimal, and confirmation of the offending food(s) requires well-designed challenge tests.
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Affiliation(s)
- Adina Kay Knight
- Section of Allergy and Immunology, Louisiana State University Health Sciencs Center, Shreveport 71130, USA.
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91
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Kaplan AP, Greaves MW. Angioedema. J Am Acad Dermatol 2006; 53:373-88; quiz 389-92. [PMID: 16112343 DOI: 10.1016/j.jaad.2004.09.032] [Citation(s) in RCA: 196] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2004] [Revised: 09/23/2004] [Accepted: 09/23/2004] [Indexed: 11/29/2022]
Abstract
UNLABELLED Although first described more than 130 years ago, the pathophysiology, origin, and management of the several types of angioedema are poorly understood by most dermatologists. Although clinically similar, angioedema can be caused by either mast cell degranulation or activation of kinin formation. In the former category, allergic and nonsteroidal anti-inflammatory drug-induced angioedema are frequently accompanied by urticaria. Idiopathic chronic angioedema is also usually accompanied by urticaria, but can occur without hives. In either case, an autoimmune process leading to dermal mast cell degranulation occurs in some patients. In these patients, histamine-releasing IgG anti-FcepsilonR1 autoantibodies are believed to be the cause of the disease, removal or suppression by immunomodulation being followed by remission. Angiotensin-converting enzyme inhibitor-induced angioedema is unaccompanied by hives, and is caused by the inhibition of enzymatic degradation of tissue bradykinin. Hereditary angioedema, caused by unchecked tissue bradykinin formation, is recognized biochemically by a low plasma C'4 and low quantitative or functional C'1 inhibitor. Progress has now been made in understanding the molecular genetic basis of the two isoforms of this dominantly inherited disease. Recently, a third type of hereditary angioedema has been defined by several groups. Occurring exclusively in women, it is not associated with detectable abnormalities of the complement system. Angioedema caused by a C'1 esterase inhibitor deficiency can also be acquired in several clinical settings, including lymphoma and autoimmune connective tissue disease. It can also occur as a consequence of specific anti-C'1 esterase autoantibodies in some patients. We have reviewed the clinical features, diagnosis, and management of these different subtypes of angioedema. LEARNING OBJECTIVE After completing this learning activity, participants should be aware of the classification, causes, and differential diagnosis of angioedema, the molecular basis of hereditary and non-hereditary forms of angioedema, and be able to formulate a pathophysiology-based treatment strategy for each of the subtypes of angioedema.
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Affiliation(s)
- Allen P Kaplan
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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92
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Hischenhuber C, Crevel R, Jarry B, Mäki M, Moneret-Vautrin DA, Romano A, Troncone R, Ward R. Review article: safe amounts of gluten for patients with wheat allergy or coeliac disease. Aliment Pharmacol Ther 2006; 23:559-75. [PMID: 16480395 DOI: 10.1111/j.1365-2036.2006.02768.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
For both wheat allergy and coeliac disease the dietary avoidance of wheat and other gluten-containing cereals is the only effective treatment. Estimation of the maximum tolerated amount of gluten for susceptible individuals would support effective management of their disease. Literature was reviewed to evaluate whether an upper limit for gluten content in food, which would be safe for sufferers from both diseases, could be identified. When setting gluten limits for coeliac disease sufferers, the overall potential daily intake should be considered, while for wheat allergy limits should be based on single servings. For coeliac disease sufferers this limit should lie between 10 and 100 mg daily intake. For wheat allergy, lowest eliciting doses for children lie in the lower milligram range, while for adults they are most significantly higher. Gliadins (part of the gluten proteins) not only trigger coeliac disease, but are also major allergens in wheat allergy. Therefore, measurement of gliadins with validated enzyme-linked immunosorbent assay methods provides an appropriate marker for assessing gluten and/or wheat protein contents in food. Available data suggest that a maximum gluten content for 'gluten-free' foods could be set, which protects both wheat allergy sufferers and coeliac patients.
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93
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Kozai H, Yano H, Matsuda T, Kato Y. Wheat-dependent exercise-induced anaphylaxis in mice is caused by gliadin and glutenin treatments. Immunol Lett 2006; 102:83-90. [PMID: 16154206 DOI: 10.1016/j.imlet.2005.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2004] [Revised: 06/17/2005] [Accepted: 07/13/2005] [Indexed: 11/18/2022]
Abstract
Various foods may be associated with food-dependent exercise-induced anaphylaxis (FDEIAn). However, although the most frequently reported cause of FDEIAn has been wheat, the mechanism of FDEIAn for wheat has remained largely uninvestigated. To investigate the effect of wheat-fractionated proteins on FDEIAn, female B10.A mice (16-20 g) were divided into four groups; i.e. salt-soluble (S-group), gliadin-rich (GLI-group), and glutenin-rich (GLU-group)-sensitized mice, and unsensitized mice. The three sensitized groups were run on a treadmill after oral intake of each wheat-fractionated protein. The mice showed a significant increase in serum IgE, especially in the GLI- and GLU-group. After oral administration of each wheat-fractionated protein, the running time until exhaustion was remarkably shorter for the GLI- and GLU-group than for the S-group and unsensitized mice. The level of intestinal erosion was higher in all the sensitized mice than that in the unsensitized ones after exhaustive running. Furthermore, moderate exercise for 30 min after oral ingestion of each wheat-fractionated protein also induced intestinal erosion in the GLI- and GLU-group. In addition, we observed leaking of gliadin and glutenin proteins out of the intestine into the liver. These results indicated that the main factor involved in wheat-dependent exercise-induced anaphylaxis might be the gliadin and glutenin in wheat proteins.
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Affiliation(s)
- Hana Kozai
- Department of Comprehensive Rehabilitation, Osaka Prefecture University, 3-7-30 Habikino, Habikino, Osaka 583-8555, Japan.
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94
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Weichel M, Vergoossen NJ, Bonomi S, Scibilia J, Ortolani C, Ballmer-Weber BK, Pastorello EA, Crameri R. Screening the allergenic repertoires of wheat and maize with sera from double-blind, placebo-controlled food challenge positive patients. Allergy 2006; 61:128-35. [PMID: 16364168 DOI: 10.1111/j.1398-9995.2006.00999.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Food allergy to wheat and maize is an increasing factor of deterioration of life quality, especially childhood and can, in rare cases, even induce anaphylaxis. Although omega-5 gliadin from wheat and maize lipid transfer protein have been characterized as major cereal allergens on the molecular level, the list of food allergens is far to be complete. METHODS To identify the IgE-binding repertoires of wheat and maize we screened respective cDNA libraries displayed on phage surface with sera from patients with a confirmed food allergy. The study included six patients with a positive double-blind, placebo-controlled food challenge (DBPCFC) to wheat, nine patients with a positive DBPCFC to maize, and six patients with anaphylactic reactions after ingestion of wheat. RESULTS The enriched sequences encoding IgE-binding proteins showed heterogeneous repertoires for both, wheat and maize. The selected wheat repertoire yielded 12, the maize repertoire 11 open reading frames. Among these we identified allergens belonging to already characterized allergens families, such as gliadin, profilin and beta-expansin. Besides, we found novel proteins with high cross-reactive potential, such as thioredoxins, as well as sequences that had so far not been related to cereal allergy at all. The IgE-binding capacity of some selected proteins was evaluated in vitro and cross-reactivity was demonstrated by competition ELISA. CONCLUSION With regard to the heterogeneity of the characterized sequences as well as to the biochemical nature of the new allergens detected we conclude that wheat and maize-related food allergy is more complex than so far anticipated.
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Affiliation(s)
- M Weichel
- Swiss Institute of Allergy and Asthma Research (SIAF), Davos Platz, Switzerland
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95
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96
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Takahama H, Tsutsumi Y, Fuke Y, Hayashida H, Watanabe M. Mallory-Weiss syndrome secondary to vomiting caused by wheat-induced anaphylaxis. Clin Exp Dermatol 2005; 29:682-3. [PMID: 15550156 DOI: 10.1111/j.1365-2230.2004.01633.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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97
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Daengsuwan T, Palosuo K, Phankingthongkum S, Visitsunthorn N, Jirapongsananuruk O, Alenius H, Vichyanond P, Reunala T. IgE antibodies to omega-5 gliadin in children with wheat-induced anaphylaxis. Allergy 2005; 60:506-9. [PMID: 15727584 DOI: 10.1111/j.1398-9995.2004.00656.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Wheat can cause severe immunoglobulin E (IgE)-mediated systemic reactions including anaphylaxis but knowledge on relevant wheat allergens at the molecular level is scanty. METHODS Seven children (aged from 6 months to 13 years) experiencing from 2 to 10 anaphylactic reactions in a year after eating food-containing wheat were examined. Purified omega-5 gliadin was used as an allergen in IgE enzyme-linked immunosorbent assay (ELISA) and in skin prick testing (SPT). Wheat CAP radioallergosorbent test (RAST) and SPT were also examined. RESULTS All seven anaphylactic children, but none of 15 control subjects had IgE antibodies to omega-5 gliadin in ELISA. Five of the six tested anaphylactic children showed positive SPT to omega-5 and crude gliadin, and all seven had positive wheat CAP RAST and SPT. One child was challenged with wheat, which caused anaphylaxis. After adherence to a wheat-free diet four children remained symptomless and three experienced one to two anaphylactic reactions. CONCLUSION The present results show that wheat omega-5 gliadin is a major sensitizing allergen in children with wheat-induced anaphylaxis. They also suggest that omega-5 gliadin IgE ELISA could be used as a diagnostic test for this severe allergy.
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Affiliation(s)
- T Daengsuwan
- Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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98
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Spergel JM, Fiedler J. Food allergy and additives: triggers in asthma. Immunol Allergy Clin North Am 2005; 25:149-67. [PMID: 15579369 DOI: 10.1016/j.iac.2004.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Jonathan M Spergel
- Department of Pediatrics, Division of Allergy and Immunology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 34th Sreet and Civic Center Blvd, Philadelphia, PA 19104, USA.
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99
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Zuberbier T, Edenharter G, Worm M, Ehlers I, Reimann S, Hantke T, Roehr CC, Bergmann KE, Niggemann B. Prevalence of adverse reactions to food in Germany - a population study. Allergy 2004; 59:338-45. [PMID: 14982518 DOI: 10.1046/j.1398-9995.2003.00403.x] [Citation(s) in RCA: 233] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE A population study was performed to identify the prevalence of all kinds of adverse reactions to food. METHODS In a representative cross-sectional survey performed in 1999 and 2000 in Berlin, 13 300 inhabitants of all ages were addressed by questionnaire. This questionnaire was answered by 4093 persons. All respondents mentioning any sign of food intolerance or the existence of allergic diseases (n = 2298) were followed up by telephone and, in case food intolerance could not be ruled out by patient history, were invited to attend to the clinic for personal investigation including double-blind, placebo-controlled food challenge tests (DBPCFC). RESULTS The self-reported lifetime prevalence of any adverse reaction to food in the Berlin population (mean age 41 years) was 34.9%. Eight hundred and fourteen individuals were personally investigated according to the guidelines. The point prevalence of adverse reactions to food confirmed by DBPCFC tests in the Berlin population as a mean of all age groups was 3.6% (95% confidence interval [3.0-4.2%]) and 3.7% in the adult population (18-79 years, 95% confidence interval [3.1-4.4.%]). Two and a half percent were IgE-mediated and 1.1% non-IgE-mediated, females were more frequently affected (60.6%). Based on a statistical comparison with available data of adults from the nationwide German Health Survey from 1998, adverse reactions to food in the adult population of Germany (age 18-79) were calculated with 2.6% [2.1-3.2%]). CONCLUSIONS The study gives for the first time information about the point prevalence of both immunological and nonimmunological adverse reactions to food and underlines the relevance of this issue in public health. The data also show that an individualized stepwise approach including provocation tests is mandatory to confirm the diagnosis.
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Affiliation(s)
- T Zuberbier
- Department of Dermatology and Allergy, University Hospital Charité, Humboldt University, Germany
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Palosuo K, Varjonen E, Nurkkala J, Kalkkinen N, Harvima R, Reunala T, Alenius H. Transglutaminase-mediated cross-linking of a peptic fraction of omega-5 gliadin enhances IgE reactivity in wheat-dependent, exercise-induced anaphylaxis. J Allergy Clin Immunol 2003; 111:1386-92. [PMID: 12789243 DOI: 10.1067/mai.2003.1498] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with wheat-dependent, exercise-induced anaphylaxis (WDEIA) experience recurrent anaphylactic reactions when exercising after ingestion of wheat products. We have identified omega-5 gliadin (Tri a 19) as a major allergen in WDEIA, but the role of exercise in eliciting the symptoms remains obscure. OBJECTIVE The aim was to examine whether tissue transglutaminase (tTG)-mediated cross-linking could be involved in modulating the IgE-binding ability and in vivo reactivity of digested omega-5 gliadin peptides in WDEIA. METHODS Purified omega-5 gliadin was digested with pepsin or with pepsin and trypsin and treated with tTG. The binding of IgE antibodies in pooled sera from 10 patients with WDEIA was studied by means of immunoblotting before and after tTG treatment of the digested peptides. The peptides derived from pepsin digestion were separated by means of gel-filtration chromatography, and IgE reactivity of 4 different peptide fractions was studied by immunoblotting before and after tTG treatment. The fraction showing the greatest degree of cross-linking by tTG was further studied by means of IgE ELISA, ELISA inhibition, and skin prick testing. RESULTS The IgE-binding ability of omega-5 gliadin was retained after pepsin and pepsin-trypsin digestion. tTG treatment of the whole peptic digest formed large peptide complexes, with molecular weights ranging from 40 to greater than 200 kd. These cross-linked aggregates bound IgE antibodies in immunoblotting more intensely than untreated, pepsin-digested, or pepsin-trypsin-digested omega-5 gliadin. A gel-filtration fraction of the whole peptic digest corresponding to the highest peak of the chromatogram and showing the greatest degree of tTG-mediated cross-linking showed an increase in serum IgE reactivity in ELISA after tTG treatment, as well as a shift of reactivity to cross-linked complexes. In the 20 patients with WDEIA, the mean skin prick test wheal elicited by this tTG-treated peptic fraction was 77% larger (P <.001) than that elicited by the untreated peptic fraction and 56% larger (P <.01) than that elicited by intact omega-5 gliadin. CONCLUSIONS Omega-5 gliadin-derived peptides are cross-linked by tTG, which causes a marked increase in IgE binding both in vitro and in vivo. Activation of tTG during exercise in the intestinal mucosa of patients with WDEIA could lead to the formation of large allergen complexes capable of eliciting anaphylactic reactions.
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Affiliation(s)
- Kati Palosuo
- Department of Dermatology, Hospital for Skin and Allergic Diseases, University of Helsinki, Helsinki, Finland
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