Sara Gralitzer

Exercise Induced Anaphylaxis: A Case Report

Introduction:
Exercise induced anaphylaxis is a rare and potentially life threatening reaction.13
Exercise induced anaphylaxis (EIAn) may be seen with specific triggers such as different foods.
When food is a trigger with exercise induced anaphylaxis then it is deemed food dependent
exercise induced anaphylaxis (FDEIAn).1 EIAn can occur from mild, moderate or more
strenuous exercise. The most common type of exercise associated with EIAn are moderate
exercises such as jogging, although it is possible for mild exercise such as walking to trigger
EIAn.1,2,46
For food dependent anaphylaxis, the most common food associated is wheat. Other foods
such as nuts, milk and shellfish can also be implicated with FDEIAn.7,8 EIAn can occur from
contact with other cofactors as well, these are hot and cold temperature, drugs such as NSAIDs,
humidity, menstrual cycle, and pollen season.9 This reaction does not occur each time the person
exercises making it difficult to know when a reaction will occur. With FDEIAn, as long as the
person avoids the specific food causing the reaction, he or she will not have a reaction exercising.
The purpose of this case report is to present the uniqueness of exercise induced anaphylaxis and
the difficulty there can be in diagnosing it.
Case Report
An 18-year-old male NCAA (National Collegiate Athletic Association) division 1
collegiate cross country runner, reported to the athletic trainer in February 2014, with complaints
of abdominal cramps and diarrhea after a difficult practice. He stated that he has had these
symptoms in the past but today it was interfering with practice. Upon questioning about what he
ate before practice, he said he did not eat anything new or different. He stated he had a history
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nasal congestion, sneezing, runny nose, coughing, wheezing, chest congestion, abdominal
cramps and diarrhea with intense exercise. His abdominal cramps tend to last to the next day,
while his coughing tends to last a few days and his wheezing will last a couple hours. He
reported that his face starts to burn and becomes flushed during these episodes. He denies any
itching or angioedema. The symptoms started 3 years ago and the intensity of the symptoms has
not changed. These symptoms do not occur all the time. When the athlete reported to us the next
day he reported he still had abdominal cramps but no other symptoms. His symptoms occur
during intense running workouts such as interval training or tempo workouts and occur about
50% of the time. Due to this occurring in the past we referred him to the team physician. He
stated if he eats some fruit or applesauce before practice then his abdominal cramps are not as
bad. The athlete stated that his symptoms are worse on hot days.
He has a history of seasonal allergies with more severe symptoms in the spring and
summer. His symptoms for seasonal allergies include sneezing, running nose, nasal congestion,
and maybe some wheezing. These symptoms respond to his albuterol inhaler and Singulair. The
athlete has an Albuterol inhaler, which he uses and it helps with his wheezing, but not with any
of his other symptoms during intense workouts. Treatments in the past have included
montelukast, fluticasone propionate, and albuterol. His doctor prescribed him epinephrine but he
has not used it.
Our differential diagnosis included Celiac Disease, Crohns Disease; exercise induced
asthma, allergies, and exercise induced anaphylaxis. We referred the athlete to the team
physician who then referred him to an allergist for further testing. While the athlete was waiting
to see the allergist he was not participating in any practices. The allergist ran tests for celiac
disease; skin testing, and pulmonary function tests. The athlete has had a previous Upper
Gastrointestinal Endoscopy (EGD) and colonoscopy in his home state. According to the athlete
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his EGD and colonoscopy, showed mild irritation of his gastric mucosa but was otherwise
normal. He tested negative for celiac disease. His skin testing results showed the following: large
reactions to both trees and grasses, smaller reactions to pollinating weeds and molds, a slight
reaction to cats, and a substantial reaction to the house dust mite. His pulmonary function tests
showed a borderline to minimal decrease in FEF 25-75 (forced expiratory flow) and FEV (forced
expiratory volume). Physical examination showed moderate nasal mucosal edema and pallor
with clear nasal mucous. Mild cobblestoning and erythema were seen in the pharynx, indicating
postnasal drainage. His skin was normal and chest was clear.
The allergist diagnosed him with exercise induced anaphylaxis, extrinsic asthma, and
allergic rhinitis. He was then started on montelukast, cetirizine 200mg daily,
mometasone/formoterol 200/5 two puffs daily, and epinephrine as needed for severe reactions.
The epinephrine can be repeated in 20 minutes if necessary. He was told that he does not need to
go to the emergency room each time he uses his epinephrine, but he does have to go to
emergency room if he requires a second dose. The athlete was instructed to not exercise alone
and to always carry his epinephrine. He was allowed to start participating in team practices after
one week of taking the medications. He was instructed to stop exercising if he feels any
symptoms starting to occur. We explained to his coach that he was to stop exercising if any
symptoms occur as well. He did not have any symptoms when he returned to the team. He was
only practicing for a couple weeks before the semester ended and the athlete returned home.
This case is unique in exercise induced anaphylaxis is a rare allergy, which is not seen, often in
athletic training and the way the case presented itself. This case was atypically due to the fact he
had no itching, urticaria, or headache.
Discussion

Anaphylaxis is defined as a potentially fatal systemic hypersensitivity reaction which will

involve several organs systems, with the skin, respiratory tract, gastrointestinal tract, and
cardiovascular tract involved.2,10 Anaphylaxis is a clinical syndrome with symptoms such as
flushing, pruritus, angioedema, rhinitis, urticaria, wheezing and syncope.2,8 Anaphylactic
reactions can range from mild to severe. Common symptoms of EIAn and FDEIAn include
pruritus, generalized feeling of warmth, flushing, urticaria, sweating, angioedema, abdominal
pain, nausea, diarrhea, dysphagia, chest tightness, wheezing, shortness of breath, and a headache
that can persist for several hours following the attack.37,11 Our athlete exhibited the following
symptoms: nasal congestion, sneezing, runny nose, coughing, wheezing, chest congestion,
abdominal craps and diarrhea. His symptoms differ from the typical symptoms seen due to the
fact he did not experience any urticaria, itching, or headache. The most common anaphylactic
triggers are medicines, latex, insect stings, food, and exercise. It is noted that about 5-15% of
anaphylactic reactions occur due to exercise. This number seems to be increasing with more
people exercising daily in developed countries.4,8,12
Exercise induced anaphylaxis most often occurs between the ages 4-74 and both genders
are affected.9 It is believed that between 30-50% of exercise induced anaphylaxis are food
dependent. Anaphylactic reactions do not always occur.9 Exercise induced anaphylaxis is on a
spectrum of transient cutaneous disorders which include cholinergic pruritus, cholinergic
urticaria, and exercise induced anaphylaxis.11 These disorders should be apart of the differential
diagnosis. There is a strong association between atopic disorders such as allergic rhinitis, asthma,
and eczema with exercise induced anaphylaxis. If the patient is diagnosed before the age of 20,
there is a strong likelihood the patient also has an atopic condition.4 As the athlete ages,
symptoms may stay the same or decrease. This can attribute to modification of exercise and
avoiding food triggers. It does not appear to worsen in severity with age.11,13
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The pathophysiology behind exercise induced anaphylaxis is not well understood but it is
believed to have to do with mediators being released from the mast cells.14,15 The differential
diagnosis should include cholinergic urticarial, cholinergic pruritus, cold induced urticaria,
exercise induced asthma, idiopathic anaphylaxis, systemic mastocystosis, cardiovascular and
respiratory diseases.4,11,8,14 To diagnose EIAn a comprehensive history is needed. An exercise
challenge test and a food induced exercise challenge test may be performed but these do not
always reflect if the reaction occurs, as a negative test result does not rule out the disease but a
positive test will help rule it in.9 Other tests such as pulmonary function tests and skin testing
may be used as well to determine what else the patient is allergic to.11,9,14
Treatment of EIAn and FDEIAn includes stopping all activity, epinephrine, H1
antihistamines, and sometimes steriords.4,8,11,14,16 Prevention includes avoiding food that triggers
the reaction 6 hours before exercise and 4 hours after exercise and stopping exercise when
symptoms start to occur in FDEIAn.14,16 Prophylactic medications include H1 and H2
antihistamines, may be of some assistance in preventing an attack but these do not always
help.1,3,14 The athlete should not exercise alone and should always carry epinephrine. The person
the athlete is exercising with should be knowledgeable of exercise induced anaphylaxis.6,11,9,16
Our athlete was advised to always carry his epinephrine while running and to always have a
partner with him. For our athlete his allergist told him he does need to go the Emergency Room
each time he has to use his epinephrine, only when he has to use the second dose. A second dose
of epinephrine may be needed in a biphasic reaction.8
Conclusion
Although Exercise induced anaphylaxis and food dependent exercise induced
anaphylaxis are rare, they do occur and the frequency of the diagnosis seems to be increasing.
This could be due to clinicians are better able to recognize this hypersensitivity or more people
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are exercising. It is important to recognize exercise induced anaphylaxis as it is a condition,

which can affect athletes. We thought it was important to write about this case because exercise
induced anaphylaxis is a rare allergy and others should be informed of this type of reaction.

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Diagnosis and Treatment. Curr. Allergy Asthma Rep. 2011;11(1):45-51.

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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.
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Morita E, Chinuki Y, Takahashi H. Recent advances of in vitro tests for the diagnosis of
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Newsham KR. Exercise-Induced Anaphylaxis: A Food-Dependent Variant. Int. J. Athl.

Ther. Train. 2014;19(1):1-5.

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Dascola CP, Caffarelli C. Exercise-induced anaphylaxis: A clinical view. Ital. J. Pediatr.

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10. Wlbing F, Biedermann T. Augmentation to Anaphylaxis: The Role of Aspirin and

Physical Exercise as Co-factors. Acta Derm. Venereol. 2012;92(5):451-453..
11. Sabroe RA. Cholinergic Urticaria and Exercise-Induced Anaphylaxis. In: Zuberbier T,
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Immunol. 2012;23(1):11-20.
13. Carlsen KH, Anderson SD, Bjermer L, et al. Exercise-induced asthma, respiratory and
allergic disorders in elite athletes: epidemiology, mechanisms and diagnosis: Part I of the
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Exercise Induced Anaphylaxis: A Case Study

Gralitzer, SL: Weber State University
Background: An 18-year-old male collegiate cross-country runner reported to the athletic
trainer in February 2014, complaining of abdominal cramps and diarrhea after a difficult practice.
He had a history of nasal congestion, wheezing, coughing, sneezing, runny nose, chest
congestion, abdominal cramps and diarrhea with intense exercise. The athlete had a history of
seasonal allergies. He stated if he uses his albuterol it helps with his wheezing but not any of his
other symptoms. He reported if he ate a small amount of applesauce or fruit prior to workouts his
abdominal symptoms were decreased. The athlete was not allowed to practice until he saw the
allergist. He was referred to the team physician and an allergist. Differential Diagnosis: The
differential diagnosis included celiac disease, exercise induced asthma, allergies, and exercise
induced anaphylaxis. Treatment: The allergist ran tests for celiac disease, pulmonary function
tests, and skin tests for allergies. He tested negative for celiac disease. His pulmonary function
tests showed borderline to minimal decrease in FEF 25-75 and FEV. Skin tests showed large
reactions to both trees and grasses, smaller reactions to pollinating weeds and molds, a slight
reaction to cats, and substantial reaction to house dust mites. The athlete was diagnosed with
exercise induced anaphylaxis, extrinsic asthma, and allergic rhinitis. He was started on
montelukast, cetirizine 200mg daily, mometasone/formoterol 200/5 two puffs daily, and
epinephrine for severe reactions. He was advised to take one dose of epinephrine if he had a
severe reaction and to take a second dose 20 minutes later if needed. The athlete was allowed to
start running in April 2014, after one week of taking the medications. When he returned to
running he did not have any symptoms. He left a few weeks later to go home for summer break.
Uniqueness: Exercise induced anaphylaxis is a rare allergy. The athlete did not present with
typical symptoms as he did not have any itching, urticaria, or headache, which is typically
associated with exercise induced anaphylaxis. Food dependent exercise induced anaphylaxis
involves ingesting a certain food prior to or just after exercise and having symptoms of
anaphylaxis. The athlete felt if he ate small amounts of applesauce or fruit prior to workouts his
abdominal symptoms were decreased. Exercise induced anaphylaxis can occur with mild,
moderate, or vigorous exercise. Conclusions: For this athlete his exercise induced anaphylaxis
presented only with high intensity or tempo workouts. Symptoms were not present for every high
intensity workout. Symptoms include nasal congestion, wheezing, coughing, sneezing, runny
nose, chest congestion, abdominal cramps and diarrhea. It is important to know about exercise
induced anaphylaxis because it is a rare allergy that can occur during sports participation. Word
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