Delayed food-dependent, exercise-induced anaphylaxis

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.

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.

How to manage food dependent exercise induced anaphylaxis (FDEIA)

PURPOSE OF REVIEW

In recent years, the number of reports on food-dependent exercise-induced anaphylaxis (FDEIA) has been increasing. This review aims to describe the standard management of FDEIA including provocation tests and identify the issues that remain unclear.

RECENT FINDINGS

Provocation tests with aspirin for FDEIA enable us to confirm the definitive diagnosis and to make differential diagnosis. In some cases, FDEIA symptoms can be induced by aspirin and the causative food without exercise. Exercise may only be an augmenting factor of FDEIA, similar to aspirin or alcohol.

SUMMARY

The mechanisms of FDEIA development remain unclear. It has been suggested that in FDEIA, exercise lowers the threshold of a food allergy. Further research is needed to elucidate the mechanism of FDEIA and to establish strategies for effective disease management.

Exercise-Induced Anaphylaxis: Literature Review and Recent Updates

PURPOSE OF REVIEW

This paper will review the pathophysiology, diagnosis, and treatment of exercise-induced anaphylaxis and food-dependent, exercise-induced anaphylaxis with an emphasis on novel studies published in the past several years.

RECENT FINDINGS

Exercise-induced anaphylaxis (EIAn) is a clinical syndrome characterized by anaphylaxis during or shortly after physical exertion. The syndrome is broadly grouped into two categories: exercise-induced anaphylaxis and food-dependent, exercise-induced anaphylaxis (FDEIAn). Recent literature indicates that FDEIAn is a primary IgE-mediated food allergy which is augmented by several cofactors. Cofactors such as exercise, NSAIDs, and alcohol increase intestinal permeability and allow increased antigen uptake, thereby causing symptoms. The pathophysiology of EIAn is still under investigation. EIAn and FDEIAn are rare clinical syndromes characterized by symptoms during or shortly after exercise. Despite recent advances in the understanding of EIAn and FDEIAn, the pathophysiology of both conditions is not fully understood.

Gluten sensitivities and the allergist: Threshing the grain from the husks

"Gluten sensitivity" has become commonplace among the public. Wheat allergy (WA) and celiac disease (CD) are well-defined entities, but are becoming a fraction of individuals following a gluten-free diet (GFD). Wheat allergy has a prevalence of <0.5%. Wheat, specifically its omega-5 gliadin fraction, is the most common allergen implicated in food-dependent, exercise-induced anaphylaxis. CD is a non-IgE hypersensitivity to certain cereal proteins: gluten in wheat, secalin in rye, hordein in barley, and to a lesser extent avenin in oat. It is a rare disease, with an estimated prevalence that varied widely geographically, being higher in Northern Europe and the African Saharawi region than in South-East Asia. In addition to suggestive symptoms, serologic testing has high diagnostic reliability and biopsy is a confirmatory procedure. Patients with CD have extra-intestinal autoimmune comorbid conditions more frequently than expected. A third entity is nonceliac gluten sensitivity, which has been created because of the increasing number of subjects who claim a better quality of life or improvement of their variety of symptoms on switching to a GFD. The phenomenon is being fueled by the media and exploited by the industry. The lack of a specific objective test has been raising substantial controversy about this entity. Allergists and gastroenterologists need to pay attention to the multitudes of individuals who elect to follow a GFD. Many such subjects might have WA, CD, or another illness. Providing them with appropriate evaluation and specific management would be of great advantages, medically and economically.

Diagnosis of exercise-induced anaphylaxis: current insights

Exercise-induced anaphylaxis (EIAn) is defined as the occurrence of anaphylactic symptoms (skin, respiratory, gastrointestinal, and cardiovascular symptoms) after physical activity. In about a third of cases, cofactors, such as food intake, temperature (warm or cold), and drugs (especially nonsteroidal anti-inflammatory drugs) can be identified. When the associated cofactor is food ingestion, the correct diagnosis is food-dependent EIAn (FDEIAn). The literature describes numerous reports of FDEIAn after intake of very different foods, from vegetables and nuts to meats and seafood. One of the best-characterized types of FDEIAn is that due to ω5-gliadin of wheat, though cases of FDEIAn after wheat ingestion by sensitization to wheat lipid transfer protien (LTP) are described. Some pathophysiological mechanisms underlying EIAn have been hypothesized, such as increase/alteration in gastrointestinal permeability, alteration of tissue transglutaminase promoting IgE cross-linking, enhanced expression of cytokines, redistribution of blood during physical exercise leading to altered mast-cell degranulation, and also changes in the acid–base balance. Nevertheless, until now, none of these hypotheses has been validated. The diagnosis of EIAn and FDEIAn is achieved by means of a challenge, with physical exercise alone for EIAn, and with the assumption of the suspected food followed by physical exercise for FDEIAn; in cases of doubtful results, a double-blind placebo-controlled combined food–exercise challenge should be performed. The prevention of this particular kind of anaphylaxis is the avoidance of the specific trigger, ie, physical exercise for EIAn, the assumption of the culprit food before exercise for FDEIAn, and in general the avoidance of the recognized cofactors. Patients must be supplied with an epinephrine autoinjector, as epinephrine has been clearly recognized as the first-line intervention for anaphylaxis.

Wheat-dependent exercise-induced anaphylaxis

Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a rare, but potentially severe food allergy exclusively occurring when wheat ingestion is accompanied by augmenting cofactors. It is clinically characterized by anaphylactic reactions ranging from urticaria and angioedema to dyspnoea, hypotension, collapse, and shock. WDEIA usually develops after ingestion of wheat products followed by physical exercise. Other cofactors are acetylsalicylic acid and other non-steroidal anti-inflammatory drugs, alcohol, and infections. The precise mechanisms of WDEIA remain unclear; exercise and other cofactors might increase gastrointestinal allergen permeability and osmolality, redistribute blood flow, or lower the threshold for IgE-mediated mast cell degranulation. Among wheat proteins, ω5-gliadin and high-molecular-weight glutenin subunits have been reported to be the major allergens. In some patients, WDEIA has been discussed to be caused by epicutaneous sensitization with hydrolysed wheat gluten included in cosmetics. Diagnosis is made based on the patient's history in combination with allergy skin testing, determination of wheat-specific IgE serum antibodies, basophil activation test, histamine release test, and/or exercise challenge test. Acute treatment includes application of adrenaline or antihistamines. The most reliable prophylaxis of WDEIA is a gluten-free diet. In less severe cases, a strict limitation of wheat ingestion before exercise and avoidance of other cofactors may be sufficient.

Exercise-induced bronchoconstriction update-2016

The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.

Evaluation of IgE Antibodies to Omalizumab (Xolair®) and Their Potential Correlation to Anaphylaxis

Omalizumab (Xolair®) is a recombinant humanized monoclonal antibody that selectively binds to human immunoglobulin E (IgE). Omalizumab is used to treat IgE-mediated diseases such as chronic idiopathic urticaria (CIU) and moderate to severe allergic asthma. In pre-marketing clinical trials in patients with asthma, anaphylaxis was reported in 3 of 3,507 (0.1%) patients. In post-marketing spontaneous reports, the frequency of anaphylaxis attributed to omalizumab use was estimated to be at least 0.2% of patients based on an estimated exposure of about 57,300 patients from June 2003 through December 2006. To better understand the risk of anaphylaxis in patients with allergic asthma receiving omalizumab, a post-marketing pharmacosurveillance study was initiated in 2009. As part of this study, an assay was developed to detect antibodies of IgE isotype to omalizumab. Serum samples from patients in the study were evaluated using this assay. Our results indicated that there was no observable correlation between either anaphylaxis or skin test reactivity and the presence of antibodies of IgE isotype to omalizumab. Here, we discuss the development of this assay as well as the results of the immunogenicity assessment.

Anaphylaxis attributed to exercise: considerations for sports medicine specialists

Anaphylaxis is an unanticipated, acute, and sometimes life-threatening systemic reaction with variable clinical presentations that is typically mediated by immunoglobulin E and causes degranulation of mast cells and basophils. The onset of symptoms can occur within minutes or hours after exposure to a known or suspected trigger, and reactions sometimes progress very rapidly, which can lead to death. One trigger of anaphylaxis in younger adults is moderately intense physical exercise, which has been termed exercise-induced anaphylaxis (EIA). Although rare, EIA should be recognized as a distinct and potentially life-threatening form of physical allergy, and is often undetected or inadequately treated. The ingestion of specific foods, including seafood, tree nuts, and wheat, or a nonspecific meal consisting of multiple food components shortly before or after physical exertion, is sometimes, but not always, the principal precipitant of EIA. This article briefly explores the current hypotheses on the role of immunoglobulin E, response mediators, and physiologic changes that bring on EIA, and discusses the current recommendations for diagnosis, including allergen challenge and laboratory testing, emergency care, and long-term prevention and patient follow-up. Accurate diagnosis of EIA is critical to providing lifesaving therapy and care plans to patients at risk. With respect to the medical management of EIA, mainstay therapy with epinephrine is described. For those with a known history of EIA, a comprehensive anaphylaxis action plan is central to successful patient management. Furthermore, patient education is necessary to heighten awareness of the signs and symptoms of EIA and appropriate strategies for allergen avoidance and self-management of anaphylactic episodes with self-injectable epinephrine.

Anaphylaxis and urticaria

Anaphylaxis and urticaria are common presenting allergic complaints. Affecting up to 2% of the population, anaphylaxis is a serious, life-threatening allergic reaction. Although not life-threatening, urticaria is a rash of transient, erythematous, pruritic wheals that can be bothersome and affects up to 25% of the population. All cases of anaphylaxis warrant thorough clinical evaluation by the allergist-immunologist, although most cases of urticaria are self-limited and do not require specialist referral. This article offers an overview of our current knowledge on the epidemiology, pathogenesis, triggers, diagnosis, and treatment of anaphylaxis and urticaria.

Wheat - Dependent Exercise-Induced Anaphylaxis Occurred With a Delayed Onset of 10 to 24 hours After Wheat Ingestion: A Case Report

Wheat-dependent exercise-induced anaphylaxis (WDEIA) usually occurs 1 to 4 hours after wheat ingestion and the pathophysiology of WDEIA remains unknown. It is recommended that WDEIA patients refrain from exercise for 4 to 6 hours after wheat ingestion. We report a case of a 51-year-old man who experienced 5 anaphylaxis attacks; two of which occurred 10 to 24 hours after wheat ingestion and exercise. He has a history of chronic gastroenteritis that responds well to antihistamine drugs but not proton pump inhibitors (PPIs) and prokinetic agents. Abdominal CT results implied the possibility of superior mesenteric artery syndrome. We suggest that WDEIA occurs 6 hours after wheat ingestion in cases compounded by obstructive gastrointestinal diseases.

Exercise-induced anaphylaxis: A clinical view

Exercise-induced anaphylaxis (EIA) is a distinct form of physical allergy. The development of anaphylaxis during exertion often requires the concomitant exposure to triggering factors such as intake of foods (food dependent exercise-induced anaphylaxis) or drugs prior to exercise, extreme environmental conditions. EIA is a rare, but serious disorder, which is often undetected or inadequately treated. This article summarizes current evidences on pathophysiology, diagnosis and management. We reviewed recent advances in factors triggering the release of mediators from mast cells which seems to play a pathogenetic role. A correct diagnosis is essential to avoid unnecessary restricted diet, to allow physical activity in subjects with EIA dependent from triggering factors such as food, and to manage attacks. An algorithm for diagnosing EIA based on medical history, IgE tests and exercise challenge test has been provided. In the long-term management of EIA, there is a need for educating patients and care-givers to avoid exposure to precipitating factors and to recognize and treat episodes. Future researches on existing questions are discussed.

The role of the gut mucosal immunity in the development of tolerance against allergy to food

PURPOSE OF REVIEW

To provide an overview on the role of gut mucosal immunity in the development of tolerance against allergy to food.

RECENT FINDINGS

The gastrointestinal tract, through innate and specific immunologic factors, acts as a defense against ingested antigens. In addition to the mucous membrane integrity and digestion, numerous specific immunologic cells and mediators orchestrate such defensive mechanisms. In case of food antigens, the outcome is usually in favor of tolerance. Defects in that barrier, however, can lead to the development of aberrant immunologic responses, including hypersensitivity reactions.

SUMMARY

The prevailing evidence is that healthy mucosal immunity plus appropriate feeding regimen during early infancy are in favor of food tolerance. However, in addition to genetic predisposition, development of allergy is facilitated by defects in the gut barrier (immune or nonimmune) and the food allergen load.

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

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

Delayed onset and protracted progression of anaphylaxis after omalizumab administration in patients with asthma

BACKGROUND

Risk of anaphylaxis is included in the prescribing information for omalizumab, but the nature of these reactions merits further elaboration.

OBJECTIVE

To describe cases of anaphylaxis associated with omalizumab administration in patients with asthma.

METHODS

We reviewed spontaneous postmarketing adverse event reports submitted to the US Food and Drug Administration's Adverse Event Reporting System database and to the manufacturers of omalizumab and cases published in the literature through December 2006. Diagnostic criteria for anaphylaxis outlined by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network were used to screen cases.

RESULTS

One-hundred twenty-four cases of anaphylaxis associated with omalizumab administration in patients with asthma were identified. Many cases had a delayed onset of symptoms beyond 2 hours after dose administration. Many cases were also characterized by a protracted progression, with individual signs and symptoms of anaphylaxis staggered over hours. Review of the case reports did not reveal any predictive risk factors for the delayed onset or protracted progression of anaphylaxis.

CONCLUSION

Omalizumab-induced anaphylaxis may be characterized by a delayed onset and a protracted progression of symptoms.

CLINICAL IMPLICATIONS

The unusual timing of anaphylaxis in these cases challenges our understanding of anaphylaxis. A delayed onset of symptoms and protracted progression of anaphylaxis should be taken into account when administering omalizumab.