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Exercise-induced anaphylaxis/Food-dependent exercise-induced anaphylaxis

Exercise-induced anaphylaxis- (EIA) is a rare condition where the anaphylaxis transpires in connection with physical activity. Food-dependent exercise-induced anaphylaxis (FDEIA) on the other hand is a sub-category of EIA and occurs when the physical activity is within a relatively short time-frame of consuming a specific food pre- or post-exercise. In 90% of cases, symptoms occur within 30 minutes although it can occur a few hours later.

Exercise Induced Anaphylaxis

Even though the first reported case of this condition was way back in 1979, there is still a lot of confusion regarding both EIA and FDEIA. This is due to a combination of the rarity of the condition (About 5-15% of all anaphylactic patients and FDEIA is estimated to be 1/3- ½ of all EIA patients) and the lack of clarity with regards to anaphylaxis in general.

Additionally, confusion about FDEIA generates because neither the food item nor the exercise alone is sufficient enough to produce an anaphylaxis reaction in the patient. However, what is known about FDEIA is that the attack is triggered in the intestines. The state of exercise triggers a mast cell degranulation to an allergen which under normal situation does not cause a reaction. This is due to, Hyperosmolality enhances mast cell degranulation and thus increases gut permeability, resulting in an increased amount of food allergen(s) presented to the mast cells and basophils.

Causes:

Both EIA and FDEIA are triggered by physical activity which includes, but is not limited to; jogging, running, biking and working out in the gym. In addition, under this large umbrella of triggers are activities ranging from lower-levels of exertion to more intense workouts. Even less understood it the reality that a specific level of exercise may trigger an attack in one occurrence but not another which results in an unpredictability factor.

Co-factors may increase risks of an attack include; aspirin and other nonsteroidal anti-inflammatory drugs, alcohol, phases of a woman’s menstrual cycle, extreme temperature and seasonal pollen exposure.

Symptoms:

Symptoms include:

  • Itching
  • Hives
  • Flushing
  • Extreme Fatigue
  • Wheezing
  • Full anaphylaxis episode resulting in throat or tongue swelling and shortness of breath

Patients may also experience nausea, abdominal cramping and diarrhea.

If the individual stops the physical activity after the symptoms first appear, there is usually an improvement in the symptoms within a few minutes, however continuing the physical activity causes the symptoms to worsen.

Treatment:

Prevention continues to be the best treatment plan for patients with EIA or FDEIA. A doctor can also provide direction and advice on how to effectively create a management plan so exercise can continue under the right circumstances which will be adapted to suit each patient’s situation and history of the condition.

Since people who are in better physical shape are less susceptible to both FDEIA and EIA than those who aren’t, doctors often recommend the patient including swimming into their weekly routine- which interestingly enough is the only exercise not reported to cause an allergic reaction.

A management plan might include:

  • Education about safe conditions for exercising
  • Identification
  • Avoidance of trigger foods (FDEIA) prior to exercise
  • Importance of discontinuing exercise immediately after symptoms appear
  • Carrying an Epi-pen while exercising
  • Appropriate use of an Epi-pen
  • Use of medical alert bracelet
  • Exercising with a partner who is aware of the patient’s condition and how to act in case of an attack
  • Use of prophylactic medications such as antihistamines

Diagnosis:

The diagnosis of both FDEIA and EIA are made based on both clinical history and a physical examination. Great importance is placed on identifying which of the two conditions (EIA/FDEIA) the patient has- a fact which is crucial to the prevention of attacks in the future.

Prognosis:

The good news is that prognosis for both FDEIA and EIA is generally favourable. Although no cure for this condition is currently known, most patients report experiencing fewer and less severe attacks over time and with appropriate lifestyle changes and keeping to a sufficient management plan can greatly shorten the episodes that do occur and possibly eliminate episodes of anaphylaxis altogether.

Additionally, a recent medical trial with the allergy department at Monash Health has had success with a medication called Omalizumab.

To read more about this condition click here for a list of medical journals and research information.

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