Endurance exercise after orange ingestion anaphylaxis
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.182526
Endurance exercise after orange ingestion cause anaphylaxis which is food-dependent exercise-induced anaphylaxis (FDEIA) which is a form of exercise-induced anaphylaxis. In this article, an individual develops symptoms such as flushing, itching, urticaria, angioedema, and wheezing after eating a food allergen and proceeds to exercise. Neither the food alone nor exercise alone is sufficient to induce a reaction. This case report describes a 36-year-old asthmatic male athlete who experienced nausea, vomiting, flushing, urticaria, and facial swelling while exercising in a gymnasium after eating oranges. Neither oranges alone nor exercise alone induced the reaction. Total avoidance of suspected food allergens would be ideal. Persons with FDEIA should keep at hand an emergency kit with antihistamines, injectable rapid action corticoids, and adrenaline. Keywords: Endurance exercise, exercise-induced anaphylaxis, food-dependent
Food-dependent exercise-induced anaphylaxis (FDEIA) is a type of exercise-induced anaphylaxis (EIA) that occurs only when a sensitized individual ingests a food allergen(s) and proceeds to exercise within a certain window of time; neither the food(s) alone nor exercise alone is sufficient to induce a reaction. Typical symptoms include flushing, generalized pruritus, urticaria, angioedema, and wheezing. [1] The following case report describes an individual who developed EIA after eating oranges while doing exercise in a gymnasium.
The patient was a 36-year-old stage male athlete who was referred to us in Government Medical College, Amritsar because of suspected orange allergy. He experienced nausea, vomiting, and generalized urticaria with facial swelling while exercising in gymnasium in March 2014 after eating oranges. He did not experience any dysphagia, wheezing, or breathing difficulties. None of the other persons present in gymnasium experienced these symptoms. He used to ate oranges on several occasions without exercising afterward and did not have any problems. He does not have any known allergies to foods or medications, nor does he have any history of eczema or asthma. He is nonsmoker and nonalcoholic. He has bronchial asthma from last 5 years for which he is taking formoterol 6 μg + budesonide 200 μg dry powder inhaler 2 puffs/day. His father is also known case of asthma from last 20 years. A complete physical examination was unremarkable, and the patient underwent skin prick testing (SPT) for all known food allergens. He had a positive reaction to citrus fruits such as orange and lemon in those SPT.
Endurance exercise following ingestion of a food allergen can lead to severe anaphylactic reactions. [2] FDEIA has been recognized as an underdiagnosed variant of EIA for almost 30 years. [3] FDEIA can be a difficult diagnosis to make because the association between the suspected food allergen(s) and physical activity is not always readily apparent. One should consider FDEIA in cases of unexplained anaphylaxis as reactions can occur several hours after ingesting the culprit food(s). The first case report of EIA in 1979 [4] described an individual who had ingested shellfish before long-distance running and subsequently developed anaphylaxis. [4] The true prevalence and incidence of FDEIA are currently unknown as many cases remain undiagnosed. There are two types of FDEIA: Unspecific FDEIA and specific FDEIA. [5] Unspecific FDEIA occurs when susceptible individual exercises after filling his or her stomach, regardless of what has been eaten. In specific FDEIA, the combination of the culprit food antigen(s) and exercise lowers mast cell degranulation thresholds, leading to histamine release and anaphylaxis. [6] The most common food implicated in specific FDEIA is wheat. [7],[8] Other triggering foods in FDEIA include chickpeas, apples, oranges, corn, mushrooms, and celery. [9],[10] The exact pathophysiology of FDEIA is not known, but gut permeability is one factor that may play an important role in the development of FDEIA. [6] The exercise can cause significant decreases in mesenteric blood flow, and that intestinal ischemia has been linked to increased bacterial translocation and absorption of endotoxin from the gastrointestinal tract. These observations suggest that mesenteric ischemia could be responsible for the failure of the gastrointestinal mucosal barrier and result in increased absorption of food allergens into the bloodstream. Another factor hypothesized to be involved in the pathophysiology of FDEIA is tissue transglutaminase (tTG) activity beneath gastrointestinal epithelium. [6] Skeletal muscle contraction during exercise increases circulating levels of tumor necrosis factor a, interleukin-6, and glucocorticoid hormones, all of which stimulate tTG activity. Thus, exercise may activate tTG and increase modification of food-derived peptides, leading to more IgE cross-linking, and mast cell degranulation. Changes in serum osmolality and pH, changes in permeability of intestinal epithelium and blood flow distribution are thought to play a role. [11] It is believed that cofactors may influence the process in two ways, by either increasing the bioavailability of food, by increasing intestinal permeability, or by decreasing the threshold for mast cell degranulation. Exercise, alcohol, and certain drugs have been shown to increase the intestinal absorption of allergens by inducing a leakage of intestinal barrier. [12] It is well-documented that exercise may reduce the threshold for mast cell and basophil activation. An important consideration in FDEIA is the relationship between the amount of food allergen ingested and the propensity for an attack. A case report on a young Japanese woman with wheat-dependent EIA by Hanakawa et al. described a dose-dependent effect of wheat ingestion on precipitating an allergic reaction [13] drug-dependent EIA has been reported in a patient on a nonsteroidal anti-inflammatory drug (NSAID), [14] and several Japanese studies have found that aspirin potentiates FDEIA. [7] Matsuo et al. demonstrated that aspirin increased circulating levels of gliadin in patients with wheat-dependent EIA, who were fed wheat. [7] Aspirin use may increase gastrointestinal absorption of food allergens and exacerbate FDEIA. With regard to skin prick tests, an Italian study on 54 patients with FDEIA recommended that those with suspected FDEIA be skin prick tested using a large panel of foods as patients can have multiple food triggers. [15] In the case reported here, the patient had a positive skin prick test against oranges. The mainstay of treatment for FDEIA is avoidance; the time course from ingestion of food allergen to development of a reaction has not been established definitively, but the Italian study by Romano et al. found that sensitized individuals did not have reactions as long as they avoided foods associated with a positive skin test for at least 4 h before exercising. Total avoidance of suspected foods would be ideal. It would also be prudent for sensitized individuals to avoid NSAIDs and aspirin if they do plan on ingesting suspected food allergens. Patients with FDEIA should be advised to carry an emergency kit with antihistamines, injectable rapid action corticoids, and adrenaline with them at all times. In an acute attack, antihistamines, corticosteroids, and/or epinephrine can be used depending on the severity of the symptoms. Currently, there are no approved prophylactic agents for FDEIA. The patient described in this report was given a prescription for an epinephrine autoinjector and instructed to avoid eating oranges before exercising in gymnasium or engaging in vigorous physical exercise. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
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