Working Diagnosis:
Food-dependent, exercise-induced anaphylaxis (FDEIA)

Treatment:
Consumption of any solid foods prior to exercise triggered symptoms for this athlete. She was instructed to avoid eating solid food 2-3 hours before exercise. She was also prescribed montelukast, an epinephrine auto-injector as well as iron supplements and vitamin D. The avoidance of solid food prior to activity led to inadequate calorie intake causing a nutritional imbalance that affected athletic performance. She underwent counseling with a sports dietician and a nutrition plan was formulated.

Outcome:
Once the nutrition plan was implemented, the patient was able to return to full athletic activities and participate in basketball games with continued avoidance of solid foods prior to physical activity. Drinking liquids before exercise did not trigger symptoms. Solid food was tolerated when not combined with exercise.

Author's Comments:
FDEIA is a rare disorder where anaphylaxis can develop if exercise is preceded by ingesting a specific food before physical activity. Patients can tolerate exercise if the food is not eaten before exercise, and patients can tolerate the food in the absence of exercise. Full anaphylaxis may not be experienced in some patients, and the reaction may manifest as urticaria or angioedema causing dyspnea. Most common trigger foods are wheat and crustaceans. Symptoms can develop more easily if cofactors like alcohol and NSAIDs are present. Diagnosis is based on patient history and provocation testing with food challenge and exercise. The pathophysiology of FDEIA remains poorly understood, but may involve IgE-mediated mast cell activation and release of vasodilatory mediators Case Photo #1 . Treatment involves education, avoidance of trigger foods and other cofactors several hours before exercise, and access to epinephrine autoinjectors. There are case reports of using omalizumab for refractory cases.

This case demonstrates a rare presentation of FDEIA because this athlete developed symptoms with consumption of any solid food before physical activity. After accurate diagnosis, treatment was successful with activity modifications and continued avoidance of solid foods prior to physical activity.

Editor's Comments:
Exercise induced anaphylaxis can be divided into four subtypes: food dependent exercise induced anaphylaxis (FDEIA) with IgE sensitivity, FDEIA without IgE sensitivity, food independent, and drug dependent exercise induced anaphylaxis. FDEIA occurs during exercise within 4-6 hours of ingesting allergenic foods (FDEIA with IgE sensitivity) or any oral intake (FDEIA without IgE). Clinical features for FDEIA include diffuse pruritis, flushing, urticaria, nausea, vomiting, diarrhea, angioedema, laryngeal edema, respiratory distress, and syncope. In FDEIA with IgE sensitivity, allergenic food consumption alone usually will not trigger an episode (unless co-triggers are present, as mentioned below). The wheat protein, omega-5-gliadin, is the most common allergen in FDEIA with IgE sensitivity; other common foods implicated in FDEIA include shellfish, peanuts, milk, corn, soybeans, rye, almonds, bee pollen, and tomatoes.

Athletes who are diagnosed with FDEIA should be counselled to not exercise within 4-6 hours of a meal, exercise with a companion, always keep an epinephrine autoinjector available, and wear a medic alert bracelet. Non-steroidal anti-inflammatory drugs (NSAIDs) increase gut permeability leading to increased food antigen exposure, and thus should be avoided prior to exercise in athletes with FDEIA. Other potential co-triggers include dust mite ingestion, alcohol ingestion, and extreme weather conditions. With proper diagnosis, education, and preparedness, the prognosis of FDEIA is very favorable for athletes to continue competing.

References:
1. Srisuwatchari W, Kanchanaphoomi K, Nawiboonwong J, Thongngarm T, Sompornrattanaphan M. Food-Dependent Exercise-Induced Anaphylaxis: A Distinct Form of Food Allergy-An Updated Review of Diagnostic Approaches and Treatments. Foods. 2023 Oct 13;12(20):3768. doi: 10.3390/foods12203768. PMID: 37893663; PMCID: PMC10606284.
2. Kulthanan K, Ungprasert P, Jirapongsananuruk O, Rujitharanawong C, Munprom K, Trakanwittayarak S, Pochanapan O, Panjapakkul W, Maurer M. Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review. J Allergy Clin Immunol Pract. 2022 Sep;10(9):2280-2296. doi: 10.1016/j.jaip.2022.06.008. Epub 2022 Jun 22. PMID: 35752432.
3. Matsuo H, Kohno K, Niihara H, Morita E. Specific IgE determination to epitope peptides of omega-5 gliadin and high molecular weight glutenin subunit is a useful tool for diagnosis of wheat-dependent exercise-induced anaphylaxis. J Immunol. 2005 Dec 15;175(12):8116-22. doi: 10.4049/jimmunol.175.12.8116. PMID: 16339549.
4. Bray SM, Fajt ML, Petrov AA. Successful treatment of exercise-induced anaphylaxis with omalizumab. Ann Allergy Asthma Immunol. 2012 Oct;109(4):281-2. doi: 10.1016/j.anai.2012.07.021. Epub 2012 Aug 15. PMID: 23010237.
5. Christensen MJ, Bindslev-Jensen C. Successful treatment with omalizumab in challenge confirmed exercise-induced anaphylaxis. J Allergy Clin Immunol Pract. 2017 Jan-Feb;5(1):204-206. doi: 10.1016/j.jaip.2016.09.035. Epub 2016 Nov 7. PMID: 27839749.

Return To The Case Studies List.