Exercise-Induced Anaphylaxis Workup

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

Approach Considerations

Workup for pediatric exercise-induced anaphylaxis includes a baseline serum tryptase level, skin and radioallergosorbent testing, and exercise challenge testing.

Next

Baseline Serum Tryptase Level

A baseline level should be normal in patients with exercise-induced anaphylaxis and food-dependent exercise-induced anaphylaxis. An elevated level at baseline suggests mastocytosis. An elevated level during an acute attack supports anaphylaxis but is not necessary to make the diagnosis and is not specific for exercise-induced anaphylaxis or food-dependent exercise-induced anaphylaxis. A negative test also does not rule out anaphylaxis.

Previous
Next

Skin and Radioallergosorbent Testing

Assessing for allergy to foods and environmental allergens with skin testing or radioallergosorbent testing (RAST) for allergen-specific immunoglobulin E ([IgE) may be useful in the evaluation of exercise-induced anaphylaxis if specific co-triggers are suspected, especially in patients with comorbidities of atopy such as allergic rhinitis or asthma. Skin testing or RAST levels are essential to the evaluation and diagnosis of patients with food-dependent exercise-induced anaphylaxis because sensitization to the precipitating food is usually demonstrable.

Previous
Next

Exercise Challenge Testing

No protocol has been established for exercise challenge to evaluate patients with exercise-induced anaphylaxis or food-dependent exercise-induced anaphylaxis. The Standard Bruce protocol for stress testing has been used by several groups with variable success in eliciting symptoms with exercise challenge.[4, 6, 32]

A positive test is useful in confirming the diagnosis of exercise-induced anaphylaxis. However, a negative test does not exclude the diagnosis.

For food-dependent exercise-induced anaphylaxis, a double-blind, placebo-controlled food-exercise challenge is the criterion standard to demonstrate the association between a specific food and the development of anaphylaxis after exercise. Due to the risk of anaphylaxis, this testing should be performed only by medical personnel trained to treat anaphylaxis.

Previous
Proceed to Treatment & Management
 
 
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.

References

  1. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. May 1984;73(5 Pt 2):699-703. [Medline].

  2. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. Aug 1980;66(2):106-11. [Medline].

  3. 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. Jul 1999;104(1):123-7. [Medline].

  4. 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. Dec 2001;108(6):1035-9. [Medline].

  5. Maulitz RM, Pratt DS, Schocket AL. Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol. Jun 1979;63(6):433-4. [Medline].

  6. Romano A, Di Fonso M, Giuffreda F, et al. Food-dependent exercise-induced anaphylaxis: clinical and laboratory findings in 54 subjects. Int Arch Allergy Immunol. Jul 2001;125(3):264-72. [Medline].

  7. Aihara Y, Kotoyori T, Takahashi Y, Osuna H, Ohnuma S, Ikezawa Z. The necessity for dual food intake to provoke food-dependent exercise-induced anaphylaxis (FEIAn): a case report of FEIAn with simultaneous intake of wheat and umeboshi. J Allergy Clin Immunol. Jun 2001;107(6):1100-5. [Medline].

  8. Soyer OU, Sekerel BE. Food dependent exercise induced anaphylaxis or exercise induced anaphylaxis?. Allergol Immunopathol (Madr). Jul-Aug 2008;36(4):242-3. [Medline].

  9. Fiocchi A, Mirri GP, Santini I, Bernardo L, Ottoboni F, Riva E. Exercise-induced anaphylaxis after food contaminant ingestion in double-blinded, placebo-controlled, food-exercise challenge. J Allergy Clin Immunol. Sep 1997;100(3):424-5. [Medline].

  10. Sanchez-Borges M, Iraola V, Fernandez-Caldas E, et al. Dust mite ingestion-associated, exercise-induced anaphylaxis. J Allergy Clin Immunol. Sep 2007;120(3):714-6. [Medline].

  11. Longley S, Panush RS. Familial exercise-induced anaphylaxis. Ann Allergy. Apr 1987;58(4):257-9. [Medline].

  12. Grant JA, Farnam J, Lord RA, Thueson DO, Lett-Brown MA, Wallfisch H. Familial exercise-induced anaphylaxis. Ann Allergy. Jan 1985;54(1):35-8. [Medline].

  13. Lewis J, Lieberman P, Treadwell G, Erffmeyer J. Exercise-induced urticaria, angioedema, and anaphylactoid episodes. J Allergy Clin Immunol. Dec 1981;68(6):432-7. [Medline].

  14. Schwartz HJ. Elevated serum tryptase in exercise-induced anaphylaxis. J Allergy Clin Immunol. Apr 1995;95(4):917-9. [Medline].

  15. Casale TB, Bowman S, Kaliner M. Induction of human cutaneous mast cell degranulation by opiates and endogenous opioid peptides: evidence for opiate and nonopiate receptor participation. J Allergy Clin Immunol. Jun 1984;73(6):775-81. [Medline].

  16. Hanakawa Y, Tohyama M, Shirakata Y, Murakami S, Hashimoto K. Food-dependent exercise-induced anaphylaxis: a case related to the amount of food allergen ingested. Br J Dermatol. May 1998;138(5):898-900. [Medline].

  17. Heyman M. Gut barrier dysfunction in food allergy. Eur J Gastroenterol Hepatol. Dec 2005;17(12):1279-85. [Medline].

  18. Fukutomi O, Kondo N, Agata H, et al. Abnormal responses of the autonomic nervous system in food-dependent exercise-induced anaphylaxis. Ann Allergy. May 1992;68(5):438-45. [Medline].

  19. Palosuo K, Varjonen E, Nurkkala J, Kalkkinen N, Harvima R, Reunala T. Transglutaminase-mediated cross-linking of a peptic fraction of omega-5 gliadin enhances IgE reactivity in wheat-dependent, exercise-induced anaphylaxis. J Allergy Clin Immunol. Jun 2003;111(6):1386-92. [Medline].

  20. Shreffler WG, Lencer DA, Bardina L, Sampson HA. IgE and IgG4 epitope mapping by microarray immunoassay reveals the diversity of immune response to the peanut allergen, Ara h 2. J Allergy Clin Immunol. Oct 2005;116(4):893-9. [Medline].

  21. Cooper DM, Radom-Aizik S, Schwindt C, Zaldivar F Jr. Dangerous exercise: lessons learned from dysregulated inflammatory responses to physical activity. J Appl Physiol. Aug 2007;103(2):700-9. [Medline].

  22. 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(4):312-5. [Medline].

  23. Tanaka S. An epidemiological survey on food-dependent exercise-induced anaphylaxis in kindergartners, schoolchildren and junior high school students. Asia Pac J Public Health. 1994;7(1):26-30. [Medline].

  24. Wade JP, Liang MH, Sheffer AL. Exercise-induced anaphylaxis: epidemiologic observations. Prog Clin Biol Res. 1989;297:175-82. [Medline].

  25. Ausdenmoore RW. Fatality in a teenager secondary to exercise-induced anaphylaxis. Pediatr Asthma Allergy Immunol. 1991;5;21.

  26. Flannagan LM, Wolf BC. Sudden death associated with food and exercise. J Forensic Sci. May 2004;49(3):543-5. [Medline].

  27. Casale TB, Keahey TM, Kaliner M. Exercise-induced anaphylactic syndromes. Insights into diagnostic and pathophysiologic features. JAMA. Apr 18 1986;255(15):2049-53. [Medline].

  28. Wanderer AA. Cold urticaria syndromes: historical background, diagnostic classification, clinical and laboratory characteristics, pathogenesis, and management. J Allergy Clin Immunol. Jun 1990;85(6):965-81. [Medline].

  29. Valent P. Diagnostic evaluation and classification of mastocytosis. Immunol Allergy Clin North Am. Aug 2006;26(3):515-34. [Medline].

  30. Cicardi M, Agostoni A. Hereditary angioedema. N Engl J Med. Jun 20 1996;334(25):1666-7. [Medline].

  31. Agostoni A, Aygoren-Pursun E, Binkley KE, et al. Hereditary and acquired angioedema: problems and progress: proceedings of the third C1 esterase inhibitor deficiency workshop and beyond. J Allergy Clin Immunol. Sep 2004;114(3 Suppl):S51-131. [Medline].

  32. Aihara M, Miyazawa M, Osuna H, et al. Food-dependent exercise-induced anaphylaxis: influence of concurrent aspirin administration on skin testing and provocation. Br J Dermatol. Mar 2002;146(3):466-72. [Medline].

  33. Simons FE. Anaphylaxis: Recent advances in assessment and treatment. J Allergy Clin Immunol. Oct 2009;124(4):625-36; quiz 637-8. [Medline].

  34. Sugimura T, Tananari Y, Ozaki Y, Maeno Y, Ito S, Yoshimoto Y. Effect of oral sodium cromoglycate in 2 children with food-dependent exercise-induced anaphylaxis (FDEIA). Clin Pediatr (Phila). Nov 2009;48(9):945-50. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.