Food dependent effort induced anaphylaxis T78.0

Maulitz 1979

Anaphylactic symptoms characterized by the fact that food can only trigger anaphylaxis in combination with augmenting factors, e.g. physical stress, including psychological stress. 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 wheal attacks for about 15 months. Last flare-up activity with circulatory problems about 3 weeks ago while jogging. He had visited a hospital emergency room and had been treated there with 250mg prednisolone and 2mg clemastine. However, these measures were not sufficient, so that intensive medical treatment was necessary to stabilize his circulation. An unrecognized insect venom allergy was suspected.

The intensified anamnesis revealed that he had already experienced milder symptoms with itchy wheals several times after his evening running training. He had done his training after work after dinner (1 glass of milk, several slices of wholemeal bread and toast with different toppings). Taking medication was very definitely denied.

Laboratory: Routine laboratory completely unremarkable. Total IgE:571kU/l (normal range: 0-100 kU/l), serum tryptase: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 within normal range.

Diagnosis. Wheat-dependent exertion-induced anaphylaxis with serologic evidence of a focus.

Therapy: Equip the patient with a shock pharmacy adrenaline autoinjector, Xusal Trp, Celestamine)

Avoidance of all wheat-containing foods before physical exertion (later running training was without complications). Change of 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.