|Year : 2014 | Volume
| Issue : 1 | Page : 52-53
A case of wheat-dependent exercise-induced anaphylaxis
Zareen Mohamed1, M. Sathiya2
1 Department of Medicine, Allergy and Asthma Clinic, Chennai, Tamil Nadu, India
2 Department of Clinical Operations, Dr. Mehta's Hospitals, Chennai, Tamil Nadu, India
|Date of Web Publication||11-Jun-2014|
Department of Medicine, Allergy and Asthma Clinic, Dr. Mehta's Hospitals, Chennai - 600 031, Tamil Nadu
Source of Support: None, Conflict of Interest: None
We report the case of a 25 year old lady who presented to our clinic with a history of repeated episodes of life threatening acute allergic reactions. After a comprehensive history analysis, her episodes were found to be triggered by physical activity after breakfast. Specific IgE antibodies to wheat was positive. Her condition was diagnosed as wheat dependant exercise induced anaphylaxis (WDEIA). Elimination of wheat products from her diet, and advice to avoid exercise after food intake prevented her further episodes of anaphylaxis
Keywords: Anaphylaxis, eia, wdeia
|How to cite this article:|
Mohamed Z, Sathiya M. A case of wheat-dependent exercise-induced anaphylaxis. Indian J Allergy Asthma Immunol 2014;28:52-3
|How to cite this URL:|
Mohamed Z, Sathiya M. A case of wheat-dependent exercise-induced anaphylaxis. Indian J Allergy Asthma Immunol [serial online] 2014 [cited 2020 Aug 4];28:52-3. Available from: http://www.ijaai.in/text.asp?2014/28/1/52/134227
| Introduction|| |
Food-dependent exercise-induced anaphylaxis (FDEIA) is a less commonly known differential diagnosis of severe allergic reactions, when anaphylaxis occurs shortly after a person participates in exercise which is temporally associated with food intake. Food-dependent exercise-induced anaphylaxis has been associated with wheat, seafood, peanut, tree nuts, eggs, milk and vegetables. Symptoms of FDEIA include urticaria, angioedema, respiratory symptoms, gastrointestinal manifestations and hypotension/shock. We describe a case of Wheat dependant exercise induced anaphylaxis in a 25 year old lady who presented to our clinic with a history of repeated episodes of anaphylaxis.
| Case report|| |
A 25-year-old woman presented to our allergy clinic for treatment for her repeated episodes of life-threatening acute allergic reactions. Her first episode happened in April 2010, while exercising she presented with generalized body itching, headache, difficulty in breathing, and vomiting with hypotension 75/60 mm Hg. She recovered completely from her anaphylactic episode after treatment at a local hospital, but had a second attack in July 2010, 3 months after her first episode, and had a third episode of anaphylaxis in November 2011. She continued to have three more episodes of anaphylaxis, before presenting to the allergy clinic for management. She is a known case of polycystic ovarian disease on treatment with metformin. Her family history was positive for atopy.
When the patient presented to the clinic for management of her condition, she was asked to narrate her episodes in detail with a help of a comprehensive allergy questionnaire. It was found that her first episode of anaphylaxis started during her morning walk after her breakfast. Her subsequent episodes had occurred during exercise or walking immediately after taking chapattis wheat bread and prawns.
Her blood work up showed eosinophils 9%, hormone levels and thyroid profile was normal. Although the skin prick test to food allergens has higher sensitivity compared with food serum-specific immunoglobulin E IgE antibodies, it was not performed on this patient as her last anaphylactic episode was less than 6 weeks ago. Immunocap enzyme-linked immunosorbent assay was ordered and against a normal serum-specific IgE cut off of 0.5 i.u./mL, her levels to wheat was 0.71 and to shell fish 0.64 i.u./mL.
Pertinent blood work up including CBC, metabolic panel, and hormonal study was within normal limits.
From the patient's clinical history and her allergy test results, her recurrent anaphylaxis was diagnosed to be food-dependent exercise-induced anaphylaxis FDEIA. The patient was strictly advised to avoid wheat products, shell fish, and to avoid exercising or walking one hour after consuming food. She was also prescribed a preventive course of mast cell stabilizer/H1 receptor antagonist ketotifen 1 mg and self-injectable epinephrine 1:1000 in the event of any sudden anaphylaxis and advised to follow-up in the clinic.
| Discussion|| |
FDEIA is a type of allergic reaction where the reaction is caused by a specific food before exercise. It can be easily missed as neither food nor exercise alone induces the symptoms. Patients with wheat-dependent exercise-induced anaphylaxis WDEIA develop anaphylaxis when exercise is performed within a 30 min to 1 h after ingestion of wheat products. 
Wheat and shrimp are the most common allergenic foods in Japan. In contrast, tomatoes are the most frequent cause in European countries.  In many countries, the most common food triggers are peanut, tree nuts, shellfish, fish, milk, egg, and sesame. 
In FDEIA, release of vasoactive mediators from mast cells may play a pathogenetic role which can be confirmed by increased serum histamine and tryptase levels within 2-4 h of reaction. Release of mast cell mediators may result in vascular leakage, inflammatory cell recruitment, and occurrence of anaphylaxis. 
The mast cell degranulation is mediated by serum specific IgE antibodies. Since exposure to the offending food alone does not elicit reaction, the theories proposed for FDEIA are pH modifications during exercise, or there is a redistribution of blood flow from the gut to skin or skeletal muscle during exercise that makes the mast cells more responsive to the causative food. Consequently, a greater exposure of the connective tissue mast cells to allergenic foods may result in an increased release of mediators and development of anaphylaxis.
In a similar case report, Ahanchian et al.,  have reported about a case of WDEIA in a 32-year-old woman attending an allergic clinic.
WDEIA was reported to be more common in adult patients, male and in cases with atopic history, particularly those less than 20 years of age. 
The diagnosis of wheat allergy is based on the patients' clinical history; detection of wheat-specific IgE and on the results of elimination diets and oral challenges.  A study from Thailand showed that a 3-day challenge protocol is a definitive diagnostic tool to confirm the diagnosis of WDEIA.  Serum IgE ratio of wheat proteins is a useful test for the diagnosis of this disease. It is better to measure the concentration of specific IgE antibodies to omega-5 gliadin than wheat and gluten. 
A correct diagnosis is essential to avoid unnecessary restricted diet, to allow physical activity in subjects with FDEIA dependent from triggering factors such as food, and to manage attacks. Careful medical history and allergy testing is critical to identify the foods that precipitate the reaction.
| References|| |
|1.||Choi JH, Lee HB, Ahn IS, Park CW, Lee CH. Wheat-dependent, Exercise-induced Anaphylaxis: A Successful Case of Prevention with Ketotifen. Ann Dermatol 2009;212:203-5. |
|2.||Harada S, Horikawa T, Icihashi M. A study of food-dependent exercise-induced anaphylaxis by analyzing the Japanese cases reported in the literature. Arerugi 2000;49:1066-73. |
|3.||Simons FE. Anaphylaxis. J Allergy Clin Immunol 2010;125:S161-81. |
|4.||Miller CW, Guha B, Krishnaswamy G. Exercise-induced anaphylaxis: A serious but preventable disease. Phys Sportmed 2008;36:87-94. |
|5.||Ahanchian H, Farid R, Ansari E, Kianifar HR, Jabbari Azad F, Jafari SA, et al. Food-dependent exercise-induced anaphylaxis due to wheat in a young woman. Iran J Allergy Asthma Immunol 2013;12:93-5. |
|6.||Aihara Y, Takahashi Y, Kotoyori T, Mitsuda T, Ito R, Aihara M, et al. Frequency of food-dependent, exercise-induced anaphylaxis in Japanese junior-high-school students. J Allergy Clin Immunol 2001;108:1035-9. |
|7.||Harada S, Iijima M, Nakamura A, Yoshizaki Y, Matsuo H, Morita E. Four cases of wheat-dependent exercise-induced anaphylaxis with negative gluten cap-rast score. Arerugi 2007;56:41-8. |
|8.||Punchama P, Jirapongsananuruk O, Daengsuwan T, Vichyanond P, Visitsunthorn N Wheat-dependent, exercise-induced anaphylaxis in Thai children: a report of 5 cases. Asian Pac J Allergy Immunol 2009;27:115-20. |
|9.||Park HJ, Kim JH, Kim JE, Jin HJ, Choi GS, Ye YM, et al. Diagnostic value of the serum-specific IgE ratio of _-5 gliadin to wheat in adult patients with wheat-induced anaphylaxis. Int Arch Allergy Immunol 2011;157:147-50. |