Exercise Induced Anaphylaxis
- Exercise-Induced Anaphylaxis
- 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
- Lifetime prevalence 0.05% to 2.0%
- Anaphylaxis has an overall has a 1-2% mortality rate
- Likely underestimated, increasing
- Exercise-Induced Anaphylaxis
- Potentially life-threatening generalized or systemic hypersensitivity reaction 
- Involves: skin, respiratory tract, gastrointestinal tract, and cardiovascular system
- 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
- 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
- Varies widely from singular episode to multiple to numerous
- Shadick et al: average of 14.5 attacks per year
- Most patients report symptoms become stable or decrease after initial episode
- Shefer and Austen Anaphylaxis Staging
- 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
- 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
- Cholingeric Urticaria
- Cold Urticaria
- Hereditary Angioedema
- Compliment Deficiency
- Neoplasm, including Pheochromocytoma
- Vasovagal Syncope
- Vocal Cord Dysfunction
- Globus hystericus
- Exercise Induced Asthma
- Exercise Induced Bronchoconstriction
- Medication reaction
- Idiopathic Anaphylaxis
- 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%)
- 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
- ABCs of airway management
- Pharmacotherapy: Epinephrine, antihistamines, corticosteroids
- Resuscitation and supportive care as indicated
- Personalized emergency action plan (EAP)
- If food dependent
- Recommend dietitian evaluation
- Avoid food triggers 3 hours prior to exercise
- 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
Rehab and Return to Play
Return to Play
- Slow, supervised return to play after sentinel event
- Needs to be updated
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- Du Toit George. Food-dependent exercise-induced anaphylaxis in childhood. Pediatr Allergy Immunol 2007; 18:455–463.
- Wade JP, Liang MH, Sheffer AL. Exercise-induced anaphylaxis: epidemiologic observations. Prog Clin Biol Res. 1989;297:175–182.
- 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
- 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.
- 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.
- 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.
- Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. 1980;6:106–111. doi: 10.1016/0091-6749(80)90056-1.
- 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.
- . 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.
- 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.
- 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.