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Exercise Induced Anaphylaxis

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Other Names

  • Exercise-Induced Anaphylaxis
  • EIA
  • Food Dependent Exercise-Induced Anaphylaxis


  • Rare syndrome of anaphylaxis associated with exercise
    • Sometimes trigged by food + exercise


  • General anaphylaxis
    • Incidence 8-50 cases per 100,000 person years[1]
    • Lifetime prevalence 0.05% to 2.0%
    • Anaphylaxis has an overall has a 1-2% mortality rate
    • Likely underestimated, increasing
  • Exercise-Induced Anaphylaxis
    • 5-15% of cases are caused by or associated with exercise[2]
    • FDEIA estimated to make up 1/3 to 1/2 of all EIA cases
    • Female > male[3]


  • Anaphylaxis
    • Potentially life-threatening generalized or systemic hypersensitivity reaction [4]
    • Involves: skin, respiratory tract, gastrointestinal tract, and cardiovascular system
    • May require food ingestion at or near time of exercise
    • Wheat is most commonly implicated food allergen[5]
    • European study: tomatoes, cereals, and peanuts[6]
  • Medication use, specifically NSAIDS, may also be a facilitating factor
  • There is no entirely safe exercise for patients with EIA
    • Trigger may be as mild as a brisk walk or raking leaves all the way to vigorous intense exercise
    • Exercise with less cardiovascular demand seems to be safer and is responsible for less than 2% of EIA episodes[7]
  • Episodes of EIA are not reliably predictable
    • Symptoms are not always repeatable and not always seen on subsequent exercise episodes
    • Exercise of the same intensity sometimes provokes symptoms, but on other occasions will not
  • Environmental factors
    • No consistent environmental factors such as extreme heat, cold, humidity
    • Warm environment (64%), high humidity (32%), and cold environment (23%) noted in one study[3]
  • Frequency
    • Varies widely from singular episode to multiple to numerous
    • Shadick et al: average of 14.5 attacks per year[7]
    • Most patients report symptoms become stable or decrease after initial episode
  • Shefer and Austen Anaphylaxis Staging[8]
    • Prodromal: fatigue and prostration and generalized pruritus with erythema.
    • Early: characterized by generalized urticaria.
    • Fully developed: gastrointestinal symptoms (abdominal cramps, nausea, and vomiting), upper airway obstruction (dyspnea, stridor, and a feeling of choking).
    • Late: frontal headache, fatigue may be present up to 72 h after the onset


  • General
    • Remains unclear in literature
    • Seen in both elite and amateur athletes
  • FDEIA proposed mechanisms
    • Alterations in plasma osmolaltiy and pH
    • Tissue enzyme activity
    • Blood flow redistribution
    • Altered gastrointestinal permeability
    • Facilitated epitope recognition/allergen binding
    • Increased basophil, histamine release[9]

Associated Conditions

Risk Factors

  • Atopy
  • Sports[3][7]
    • Jogging
    • Aerobics
    • Walking
    • Tennis/racquetball
    • Tennis
    • Racquetball
    • Dancing
    • Bicycling

Differential Diagnosis

Clinical Features

  • Symptoms by frequency
    • Pruritus (92%)
    • Urticaria (83-86%)
    • Angioedema (72-78%)
    • Flushing (70-75%)
    • Shortness of breath (51-59%)
    • Dysphagia (34%)
    • Chest tightness (33%)
    • Loss of consciousness (32%)
    • Diaphoresis (32-42%)
    • Headache (28-30%)
    • Nausea/diarrhea/colic (28-30%)
    • Choking/throat constriction/hoarseness (25%)
  • History
    • Generally follows a brief period of submaximal exercise, however can be associated with any intensity level
    • Symptom onset usually begins within 30 minutes of initiating exercise
    • Carefully review recent food intact, exposure to allergens (fluids oils, lotions, soaps, detergents, etc)
  • Severe symptoms
    • Lower airways, including dyspnea, wheezing, and chest tightness.
    • Cardiovascular symptoms, including collapse or altered consciousness


  • Diagnosis is generally made clinically based on anaphylaxis symptoms occurring during exercise
  • Skin prick testing and/or IgE antibody testing may be required and is helpful for identifying the offending food
  • In safe clinical setting, challenge athlete to establish diagnosis
    • Clinician should follow the protocol for exercise-induced bronchoconstriction


  • 'Pure' Exercise-Induced Anaphylaxis (EIA)
  • Food Dependent Exercise-Induced Anaphylaxis (FDEIA)



  • Management of EIA does not differ from other types of anaphylaxis[10]
    • ABCs of airway management
    • Pharmacotherapy: Epinephrine, antihistamines, corticosteroids
    • Resuscitation and supportive care as indicated


  • Personalized emergency action plan (EAP)
    • Avoidance of preciptating factors
    • Avoid NSAIDS prior to exercise
    • Educate, train patient and family in management
    • Have Epinephrine auto-injector available at all times
  • If food dependent
    • Recommend dietitian evaluation
    • Avoid food triggers 3 hours prior to exercise[11]
    • Avoid food triggers 1 hour post exercise
  • Medication Management
    • Role of antihistamines, antileukotriene antagonists and oral steroids as preventative therapy not well studied
    • Case reports have demonstrated positive results[12]

Rehab and Return to Play


  • N/A

Return to Play

  • Slow, supervised return to play after sentinel event


  • Needs to be updated

See Also


  1. Tang ML, Osborne N, Allen K. Epidemiology of anaphylaxis. Curr Opin Allergy Clin Immunol. 2009;9:351–356. doi: 10.1097/ACI.0b013e32832db95a
  2. Du Toit George. Food-dependent exercise-induced anaphylaxis in childhood. Pediatr Allergy Immunol 2007; 18:455–463.
  3. 3.0 3.1 3.2 Wade JP, Liang MH, Sheffer AL. Exercise-induced anaphylaxis: epidemiologic observations. Prog Clin Biol Res. 1989;297:175–182.
  4. Johansson SG, Hourihane JO, Bousquet J, et al. A revised nomenclature for allergy. Allergy. 2001;56:813–824. doi: 10.1034/j.1398-9995.2001.t01-1-00001.x
  5. ihara Y, Takahashi Y, Kotoyori T, et al. Frequency of food-dependent, exercise-induced anaphylaxis in Japanese junior-high-school students. J Allergy Clin Immunol 2001; 108:1035–1039.
  6. Romano A, Fonso M, Giuffreda F, et al. Food-dependent exercise-induced anaphylaxis: clinical and laboratory findings in 54 subjects. Int Arch Allergy Immunol. 2001;125:264–272. doi: 10.1159/000053825.
  7. 7.0 7.1 7.2 Shadick NA, Liang MH, Partridge AJ, et al. The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study. J Allergy Clin Immunol. 1999;104:123–127. doi: 10.1016/S0091-6749(99)70123-5.
  8. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. 1980;6:106–111. doi: 10.1016/0091-6749(80)90056-1.
  9. Barg W, Wolanczyk-Medrala A, Obojski A, et al. Food-dependent exercise-induced anaphylaxis: possible impact of increased basophil histamine releasability in hyperosmolar conditions. J Investig Allergol Clin Immunol 2008; 18:312–315.
  10. . Lieberman P, Decker W, Camargo CA Jr, et al.: SAFE: a multidisciplinary approach to anaphylaxis education in the emergency department. Ann Allergy Asthma Immunol 2007, 98:519–523.
  11. Aihara Y, Takahashi Y, Kotoyori T, et al. Frequency of food-dependent, exercise-induced anaphylaxis in Japanese junior-high-school students. J Allergy Clin Immunol 2001; 108:1035–1039.
  12. Peroni DG, Piacentini GL, Piazza M, et al.: Combined cetirizinemontelukast preventive treatment for food-dependent exercise-induced anaphylaxis. Ann Allergy Asthma Immunol 2010, 104:272–273.
Created by:
John Kiel on 14 June 2019 06:33:25
Last edited:
1 October 2022 22:20:13