Exerciseinduced anaphylaxis Dr Enrico Heffler enricoheffleryahoo it MD

Exercise-induced anaphylaxis Dr. Enrico Heffler (enrico_heffler@yahoo. it) MD, Specialist in Allergy and Clinical Immunology - University of Torino (Italy) Allergy Outpatients’ Clinic- “E. Agnelli” Hospital - Pinerolo (Italy) Allergy Outpatients’ Clinic – Valenza, Casale Monferrato and Acqui Terme Hospitals (Italy)

EXERCISE-INDUCED ANAPHYLAXIS DEFINITION Systemic severe reaction that arises after exercise In most of cases it is preceded by the ingestion of foods to which the patient is sensitized Altri fattori facilitanti possono essere coinvolti: (Food-Induced Exercise-Anaphylaxis) These foods, in most of cases, don’t elicit any symptoms when ingested at rest Mastocytosis / Mast cell activation syndromes

FOOD ALLERGY SIGNS AND SYMPTOMS

EXERCISE-INDUCED ANAPHYLAXIS EPIDEMIOLOGY • The first case has been describe in 1979 by Maulitz et al (JACI): after strenous exercise after having ingested crustaceans • Prevalence: • 0, 06 % in primary school’s children • 0, 21 % in high school’s adolescents • rarer in the fourth decade of life • more frequent in males (M/F=2/1) The reason is currently unknown

EXERCISE-INDUCED ANAPHYLAXIS DIFFERENTIAL DIAGNOSIS • with CHOLINERGIC URTICARIA • In anaphylaxis there also other systemic symptoms • Different morphology of wheals Cholinergic urticaria Classical urticaria • Patients with anaphylaxis don’t have symptoms after exposure to heat • Patients with anaphylaxis have symptoms almost always after ingestion of food which are sensitized to

EXERCISE-INDUCED ANAPHYLAXIS MORE FREQUENTLY INVOLVED FOODS: Vegetables 57%

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: • Aspecific mast cells degranulation • Increased levels of serum histamine • Increased intestinal absorbsion of partially digested food

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS:

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: • Other triggers may contribute to induce anaphylaxis: i. e. : Aspirin

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: • More studied example: Omega-5 Gliadin (from wheat) Suluble in ethanol Unsoluble in ethanol

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: • More studied example: Omega-5 Gliadin (from wheat)

EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: • More studied example: Omega-5 Gliadin (from wheat) It is useful to investigate recombinant specific Ig. E to better diagnose food-dependent exercise-induced anaphylaxis

EXERCISE-INDUCED ANAPHYLAXIS DIAGNOSIS • MEDICAL HISTORY is essential: · Symptoms described by the patients · Ingested foods · Period of time between food ingestion and symptoms · Severity of symptoms · Frequence of symptoms · Period of time between the last episode · Triggers: EXERCISE, EXERCISE drugs, alcohol…

EXERCISE-INDUCED ANAPHYLAXIS DIAGNOSIS • MEDICAL HISTORY is essential: • Skin Prick Tests • Specific Ig. E (CAP) for native and recombinant allergens • Food Challenges: • Only food challenge (to rule out classical food allergy) • Only exercise challenge (to rule out classical exercise-induced anaphylaxis – rare!) • Food challenge + exercise challenge (+ ASA challenge) (to confirm the diagnosis)

EXERCISE-INDUCED ANAPHYLAXIS THERAPY AND RECOMMENDATIONS FOR PATIENTS • SELF-INJECTABLE EPINEPHRINE • To avoid to do exercise after 4 -6 hours after the ingestion of foods