Food dependent effort induced anaphylaxisT78.0

Maulitz 1979

Anaphylactic symptomatology which is characterized by the fact that food is only able to trigger anaphylaxis in combination with augmentation factors, e.g. physical strain, also psychological stress. The food-dependent exercise-induced anaphylaxis belongs to the group of summation anaphylaxis.

The best-studied food-related exercise-induced anaphylaxis is wheat-related exercise-induced anaphylaxis (WDEIA). Here, allergic reactions usually occur within 2 (up to 6) hours after the consumption of wheat products (bread, cakes, pizza - see below wheat) with a cofactor (sudorific effort). It is suspected that the effort causes an activation of the tissue transglutaminase in the intestine with cross-linking of omega-5 gliadin peptides and consecutive anaphylaxis.

Such summation anaphylaxis may occur after consumption of fruit, celery, tomatoes, peanuts, hazelnuts, soya products, cow's milk or red meat.

As augmentation factors, a number of factors can be considered: Physical effort: anaphylactic reactions occur after a latency of 1-6 hours. Note: the intensity of the physical effort that triggers a critical reaction varies from one individual to another. In many cases, intense sweaty efforts (e.g. intensive sports exercise) are necessary, but sometimes a normal walk is sufficient. Other augmentation factors are:

• Drugs (especially aspirin, NSAIDs)
• Alcohol
• Infections
• Stress
• Hormonal factors (e.g. menstruation)

The extent to which mutations in the filaggrin gene can have a pathogenetic significance is still unclear.

IgE antibodies against the major allergen Omega-5Gliadin (Tri a 19) can be detected in about 80% of patients. Possibly significant increase in total IgE.

A 25-year-old patient has been reporting multiple episodes of wheals for about 15 months. The last episode with circulatory problems occurred about 3 weeks ago while jogging. He visited an emergency admission of a hospital and was treated with 250mg prednisolone and 2mg clemastine. However, these measures were not sufficient, so that intensive medical treatment was necessary to stabilize his circulation. The main reason was an unrecognized insect venom allergy.

The intensified anamnesis showed that he had already had a lessened symptomatology with itchy wheals several times after his evening running training. He carried out his training after work after dinner (1 glass of milk, several slices of wholemeal and toast bread with different toppings). Taking medication was very definitely negated.

Laboratory: Routine laboratory completely inconspicuous. Total IgE:571kU/l (normal range: 0-100 kU/l), Serumtryptase:4,45ug/l (normal range:<11,4ug/l),

Omega-5 gliadin from wheat: 13.1kU/l, RAST class 3. ASL 366 IU/ml (normal range: 200 IU/ml) C1 esterase inhibitor activity in the normal range.

Diagnosis. Wheat-dependent exercise-induced anaphylaxis with serological evidence of a focus.

Therapy: Equipping the patient with a shock pharmacy (adrenalin autoinjector, Xusal Trp, Celestamine)

Avoid all foods containing wheat before physical exertion (a later running training was without complications). Change in eating habits (avoidance of spelt and other wheat derivatives).

1. Ahanchian H et al (2013) Food-dependent exercise-induced anaphylaxis due to wheat in a young woman. Iran J Allergy Asthma Immunol 12:93-95.
2. Asaumi T et al.(2016) Provocation tests for the diagnosis of food-dependent exercise-induced anaphylaxis. Pediatric Allergy Immunol 27:44-49.
3. Hofmann C et al (2015) Molecular diagnostics for the diagnosis of food-dependent exercise-induced anaphylaxis. In: Kleine-Tebbe J et al. Hrsg Molecular allergy diagnostics. Springer Verlag Berlin-Heidelberg S 245-267.
4. Maulitz RM et al (1979) Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol 63:433-434.
5. Mizuno O et al.(2015)Loss-of-function mutations in the gene encoding filaggrin underlie a Japanese family with food-dependent exercise-induced anaphylaxis. J Eur Acad Dermatol Venereol 29:805-808.
6. Roberts H et al(2015) Food-dependent exercise-induced anaphylaxis to chickpea in a 17-year-old female: a case report. J Med Case Rep 9:186.