Approach Considerations

In an attack of acute exercise-induced anaphylaxis or food-dependent exercise-induced anaphylaxis, as with anaphylaxis in general, the focus should be on acute resuscitation and the emergency ABCs (airway, breathing, circulation). Maintenance of a patent airway and monitoring for circulatory collapse are critical.

Admit patients with exercise-induced anaphylaxis (EIA) to the intensive care unit (ICU) if mechanical ventilation and/or cardiac monitoring is required. Admit to the inpatient ward for monitoring if the patient recovers from the episode. Arrange for injectable epinephrine teaching while the patient is in the hospital.

If symptoms progress to anaphylaxis, intramuscular epinephrine is the drug of choice. Airway maintenance, oxygen therapy, fluid resuscitation, and cardiopulmonary support should be used if necessary. Surgical intervention is indicated only for patients who need emergent tracheostomy or central line access.

Long-term management of exercise-induced anaphylaxis and food-dependent exercise-induced anaphylaxis must be individualized to each patient, because the severity, frequency, intensity of exercise needed to trigger anaphylaxis and the possible association with other co-triggers all vary. Other medications, such as oral steroids, leukotriene-modifying agents, and omalizumab, are either unstudied or reported only in isolated cases.

Patients should be educated to recognize the prodromal manifestations of exercise-induced anaphylaxis so that physical activity can be discontinued at the earliest warning signs and the progression to vascular collapse can be prevented.

To see complete information on Pediatric Anaphylaxis, please go to the main article by clicking here.

Treatment & Management

Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. 1984 May. 73(5 Pt 2):699-703. [QxMD MEDLINE Link].
Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. 1980 Aug. 66(2):106-11. [QxMD MEDLINE Link].
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 Jul. 104(1):123-7. [QxMD MEDLINE Link].
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 Dec. 108(6):1035-9. [QxMD MEDLINE Link].
Maulitz RM, Pratt DS, Schocket AL. Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol. 1979 Jun. 63(6):433-4. [QxMD MEDLINE Link].
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. 2001 Jul. 125(3):264-72. [QxMD MEDLINE Link].
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. 2001 Jun. 107(6):1100-5. [QxMD MEDLINE Link].
Soyer OU, Sekerel BE. Food dependent exercise induced anaphylaxis or exercise induced anaphylaxis?. Allergol Immunopathol (Madr). 2008 Jul-Aug. 36(4):242-3. [QxMD MEDLINE Link].
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. 1997 Sep. 100(3):424-5. [QxMD MEDLINE Link].
Sanchez-Borges M, Iraola V, Fernandez-Caldas E, et al. Dust mite ingestion-associated, exercise-induced anaphylaxis. J Allergy Clin Immunol. 2007 Sep. 120(3):714-6. [QxMD MEDLINE Link].
Longley S, Panush RS. Familial exercise-induced anaphylaxis. Ann Allergy. 1987 Apr. 58(4):257-9. [QxMD MEDLINE Link].
Grant JA, Farnam J, Lord RA, Thueson DO, Lett-Brown MA, Wallfisch H. Familial exercise-induced anaphylaxis. Ann Allergy. 1985 Jan. 54(1):35-8. [QxMD MEDLINE Link].
Ansley L, Bonini M, Delgado L, Del Giacco S, Du Toit G, Khaitov M, et al. Pathophysiological mechanisms of exercise-induced anaphylaxis: an EAACI position statement. Allergy. 2015 Oct. 70 (10):1212-21. [QxMD MEDLINE Link].
Lewis J, Lieberman P, Treadwell G, Erffmeyer J. Exercise-induced urticaria, angioedema, and anaphylactoid episodes. J Allergy Clin Immunol. 1981 Dec. 68(6):432-7. [QxMD MEDLINE Link].
Schwartz HJ. Elevated serum tryptase in exercise-induced anaphylaxis. J Allergy Clin Immunol. 1995 Apr. 95(4):917-9. [QxMD MEDLINE Link].
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. 1984 Jun. 73(6):775-81. [QxMD MEDLINE Link].
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. 1998 May. 138(5):898-900. [QxMD MEDLINE Link].
Heyman M. Gut barrier dysfunction in food allergy. Eur J Gastroenterol Hepatol. 2005 Dec. 17(12):1279-85. [QxMD MEDLINE Link].
Fukutomi O, Kondo N, Agata H, et al. Abnormal responses of the autonomic nervous system in food-dependent exercise-induced anaphylaxis. Ann Allergy. 1992 May. 68(5):438-45. [QxMD MEDLINE Link].
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. 2003 Jun. 111(6):1386-92. [QxMD MEDLINE Link].
Brockow K, Kneissl D, Valentini L, Zelger O, Grosber M, Kugler C, et al. Using a gluten oral food challenge protocol to improve diagnosis of wheat-dependent exercise-induced anaphylaxis. J Allergy Clin Immunol. 2015 Apr. 135 (4):977-84.e4. [QxMD MEDLINE Link].
Christensen MJ, Eller E, Mortz CG, Brockow K, Bindslev-Jensen C. Exercise Lowers Threshold and Increases Severity, but Wheat-Dependent, Exercise-Induced Anaphylaxis Can Be Elicited at Rest. J Allergy Clin Immunol Pract. 2018 Mar - Apr. 6 (2):514-520. [QxMD MEDLINE Link].
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. 2005 Oct. 116(4):893-9. [QxMD MEDLINE Link].
Cooper DM, Radom-Aizik S, Schwindt C, Zaldivar F Jr. Dangerous exercise: lessons learned from dysregulated inflammatory responses to physical activity. J Appl Physiol. 2007 Aug. 103(2):700-9. [QxMD MEDLINE Link].
Barg W, Medrala W, Wolanczyk-Medrala A. Exercise-induced anaphylaxis: an update on diagnosis and treatment. Curr Allergy Asthma Rep. 2011 Feb. 11 (1):45-51. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Wade JP, Liang MH, Sheffer AL. Exercise-induced anaphylaxis: epidemiologic observations. Prog Clin Biol Res. 1989. 297:175-82. [QxMD MEDLINE Link].
Ausdenmoore RW. Fatality in a teenager secondary to exercise-induced anaphylaxis. Pediatr Asthma Allergy Immunol. 1991. 5;21:
Flannagan LM, Wolf BC. Sudden death associated with food and exercise. J Forensic Sci. 2004 May. 49(3):543-5. [QxMD MEDLINE Link].
Casale TB, Keahey TM, Kaliner M. Exercise-induced anaphylactic syndromes. Insights into diagnostic and pathophysiologic features. JAMA. 1986 Apr 18. 255(15):2049-53. [QxMD MEDLINE Link].
Wanderer AA. Cold urticaria syndromes: historical background, diagnostic classification, clinical and laboratory characteristics, pathogenesis, and management. J Allergy Clin Immunol. 1990 Jun. 85(6):965-81. [QxMD MEDLINE Link].
Valent P. Diagnostic evaluation and classification of mastocytosis. Immunol Allergy Clin North Am. 2006 Aug. 26(3):515-34. [QxMD MEDLINE Link].
Cicardi M, Agostoni A. Hereditary angioedema. N Engl J Med. 1996 Jun 20. 334(25):1666-7. [QxMD MEDLINE Link].
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. 2004 Sep. 114(3 Suppl):S51-131. [QxMD MEDLINE Link].
Simons FE. Anaphylaxis: Recent advances in assessment and treatment. J Allergy Clin Immunol. 2009 Oct. 124(4):625-36; quiz 637-8. [QxMD MEDLINE Link].
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). 2009 Nov. 48(9):945-50. [QxMD MEDLINE Link].
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. 2002 Mar. 146(3):466-72. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Peter N Huynh, MD Chief of Allergy and Immunology, Kaiser Permanente, Panorama City Medical Center

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, 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, American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Salima A Thobani, MD Kaiser Permanente

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

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, American College of Allergy, Asthma and Immunology

Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD Faculty, Division of Allergy/Immunology and Infectious Diseases, Department of Pediatrics, Saint Peter's University Hospital

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 Pediatric Research, Society for Mucosal Immunology

Disclosure: Nothing to disclose.

Acknowledgements

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

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.

Paul H Sammut, MBBCh, FAAP, FCCP Medical Director of the Pediatric Intensive Care Unit, Associate Professor, Department of Pediatrics, Section of Pulmonology, University of Nebraska Medical Center

Disclosure: Nothing to disclose.

William B Stratbucker, MD, Assistant Professor of Pediatrics, Division of General Academic Pediatrics, Rush Medical College; Consulting Staff, Rush University Medical Center, Rush Children's Hospital

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Exercise-Induced Anaphylaxis Workup

Approach Considerations

References

Tables

Contributor Information and Disclosures

What would you like to print?