Exercise-Induced Anaphylaxis Clinical Presentation

  • Author: Peter N Huynh, MD; Chief Editor: Harumi Jyonouchi, MD   more...
 
Updated: Mar 29, 2011
 

History

Exercise-induced anaphylaxis (EIA) is characterized by signs and symptoms of anaphylaxis in the setting of physical activity. If physical exertion continues, symptoms progress in severity. Premonitory symptoms of exercise-induced anaphylaxis attacks include diffuse warmth, pruritus, erythema, and sweating. These are followed by typical urticarial lesions and angioedema that can progress to include GI symptoms, laryngeal edema, and/or vascular collapse.

Symptoms may begin at any stage of exercise. Cessation of the physical activity usually results in immediate improvement or resolution of symptoms. However, some patients may experience vascular collapse even after exercise cessation.

The frequency of symptoms during exercise varies among patients with exercise-induced anaphylaxis and food-dependent exercise-induced anaphylaxis. Most patients exercise regularly but experience attacks only occasionally. In patients with food-dependent exercise-induced anaphylaxis, episodes typically occur when the person exercises 1-3 hours after eating. The duration of exercise prior to the development of symptoms may range from less than 30 minutes to a maximum of 45 minutes.

The most common signs and symptoms, along with their relative frequency of occurrence, are as follows[1] :

  • Pruritus (92%)
  • Urticaria (86%)
  • Angioedema (72%)
  • Flushing (70%)
  • Shortness of breath (51%)
  • Dysphagia (34%)
  • Chest tightness (33%)
  • Syncope (32%)
  • Profuse sweating (32%)
  • Headache (28%)
  • GI symptoms, including nausea, diarrhea, and colicky pain (28%)
  • Choking, throat constriction, hoarseness (25%)

Clinicians should also carefully review the events leading up to the episode of anaphylaxis with a special focus on the following:

  • Was each of the attacks associated with exercise? If not, then other causes of anaphylaxis should be investigated
  • Do symptoms subside when the patient stops physical activity?
  • Do activities that raise body temperature in the absence of exercise (eg, hot baths, saunas, or showers) induce symptoms? Symptoms triggered by changes in core body temperature are suggestive of cholinergic urticaria
  • Are any medications, changes in environment, or other exposures associated with the episodes?
  • What foods has the patient eaten before each episode?

Patients with exercise-induced anaphylaxis commonly experience attacks for over 10 years, with an average of 14 attacks per year, before their disorder is diagnosed. The frequency of attacks is diminished in patients who have avoided known triggers or reduced their physical activity.

Next

Physical Examination

Physical examination findings may be highly variable in patients with exercise-induced anaphylaxis or food-dependent exercise-induced anaphylaxis. Signs of chronic allergic disease such as eczema, “allergic shiners,” and boggy nasal mucosa suggestive of allergic rhinitis may be noted.

A careful skin examination should be performed to evaluate for dermatographism and urticaria pigmentosa, which are characteristic findings in mastocytosis. Urticaria pigmentosa is characterized by oval or round red-brown macules, papules, or plaques. Mastocytosis may present with anaphylaxis that is precipitated by exercise and in response to various different triggers; therefore, excluding this disorder is important.

Cardiac examination should be performed to exclude abnormal heart sounds because exercise-induced cardiac disorders are also in the differential.

Respiratory symptoms

During an episode, severe angioedema of the tongue and lips may obstruct airflow. Laryngeal edema may manifest as throat constriction and stridor. Hoarseness, change in voice, dysphagia, or a sensation of choking may occur. Bronchospasm, airway edema, and increased mucus production may manifest as wheezing and chest tightness.

Cardiovascular symptoms

Tachycardia usually occurs as a compensatory response to reduced intravascular volume and endogenous catecholamine release during an episode. Hypotension can occur secondary to capillary leak, vasodilatation, and myocardial depression. Cardiovascular collapse and shock can occur in the absence of other findings and patients may present with syncope.

Cutaneous symptoms

Hives can occur anywhere on the body. The lesions are generally large (giant hives) and are erythematous, raised, and highly pruritic. Angioedema is also commonly observed. These lesions involve the deeper dermal layers of skin. It is usually nonpruritic and nonpitting. Generalized flushing and profuse sweating may also be observed.

Gastrointestinal symptoms

Vomiting, diarrhea, and colicky abdominal pain are frequently observed.

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Contributor Information and Disclosures
Author

Peter N Huynh, MD  Director, Allergy and Immunology Clinic, LAC+USC Medical Center; Assistant Professor, Division of Allergy and Immunology, Keck School of Medicine of the University of Southern California

Peter N Huynh, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Edward K Hu, MD  Fellow, Division of Allergy and Immunology, LAC+USC Medical Center

Edward K Hu, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, and American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Jeffrey F Linzer Sr, MD, MICP, FAAP, FACEP  Associate Professor of Pediatrics and Emergency Medicine, Emory University School of Medicine; Associate Medical Director for Compliance and Business Affairs and EMS/Pre-Hospital Care Coordinator, Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine; Emergency Pediatric Group, Children's Healthcare of Atlanta at Egleston; Co-Medical Director and Consulting Staff, Children's Sedation Service, Children's Healthcare of Atlanta at Egleston

Jeffrey F Linzer Sr, MD, MICP, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics, American College of Allergy, Asthma and Immunology, American College of Emergency Physicians, and Medical Association of Georgia

Disclosure: Nothing to disclose.

Lyne Scott, MD  Chief, Division of Allergy and Immunology, Director, Fellowship Training Program, Director, The Breathmobile Program, LAC+USC Healthcare Network; Assistant Professor, Department of Pediatrics, Keck School of Medicine of the University of Southern California

Lyne Scott, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, and American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Salima A Thobani, MD  Fellow, Division of Allergy and Immunology, LAC+USC Medical Center

Salima A Thobani, MD is a member of the following medical societies: American College of Physicians, American Medical Student Association/Foundation, and American Medical Women's Association

Disclosure: Nothing to disclose.

Specialty Editor Board

C Lucy Park, MD  Head, Division of Allergy, Immunology, and Pulmonology, Associate Professor, Department of Pediatrics, University of Illinois at Chicago

C Lucy Park, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Medical Association, Chicago Medical Society, Clinical Immunology Society, and Illinois State Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD  Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School

Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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