1. Exercise-induced anaphylaxis Dr. Enrico Heffler (enrico_heffler@yahoo.it) MD, Specialist in Allergy and Clinical Immunology Allergy and Clinical Immunology - University of Torino (Italy) Allergy Outpatients’ Clinic- “E.Agnelli” Hospital - Pinerolo (Italy) Allergy Outpatients’ Clinic – Valenza, Casale Monferrato and Acqui Terme Hospitals (Italy)

2. DEFINITION Systemic severe reaction that arises after exercise In most of cases it is preceded by the ingestion of foods to which the patient is sensitized (Food-Induced Exercise-Anaphylaxis) Altri fattori facilitanti possono essere coinvolti: These foods, in most of cases, don’t elicit any symptoms when ingested at rest EXERCISE-INDUCED ANAPHYLAXIS Mastocytosis / Mast cell activation syndromes

3. FOOD ALLERGY SIGNS AND SYMPTOMS

4. EPIDEMIOLOGY EXERCISE-INDUCED ANAPHYLAXIS The first case has been describe in 1979 by Maulitz et al (JACI): after strenous exercise after having ingested crustaceans Prevalence: 0,06 % in primary school’s children 0,21 % in high school’s adolescents rarer in the fourth decade of life more frequent in males (M/F=2/1) The reason is currently unknown

5. DIFFERENTIAL DIAGNOSIS with CHOLINERGIC URTICARIA In anaphylaxis there also other systemic symptoms Different morphology of wheals Patients with anaphylaxis don’t have symptoms after exposure to heat Patients with anaphylaxis have symptoms almost always after ingestion of food which are sensitized to Cholinergic urticaria Classical urticaria EXERCISE-INDUCED ANAPHYLAXIS

6. MORE FREQUENTLY INVOLVED FOODS: Vegetables 57% EXERCISE-INDUCED ANAPHYLAXIS

7. INVOLVED MECHANISMS: Aspecific mast cells degranulation Increased levels of serum histamine Increased intestinal absorbsion of partially digested food EXERCISE-INDUCED ANAPHYLAXIS

8. INVOLVED MECHANISMS:

9. Other triggers may contribute to induce anaphylaxis: i.e.: Aspirin EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS:

10. More studied example: Omega-5 Gliadin (from wheat) Suluble in ethanolUnsoluble in ethanol EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS:

11. EXERCISE-INDUCED ANAPHYLAXIS INVOLVED MECHANISMS: More studied example: Omega-5 Gliadin (from wheat)

12. It is useful to investigate recombinant specific IgE to better diagnose food-dependent exercise-induced anaphylaxis More studied example: Omega-5 Gliadin (from wheat) INVOLVED MECHANISMS: EXERCISE-INDUCED ANAPHYLAXIS

13. DIAGNOSIS  Symptoms described by the patients  Period of time between food ingestion and symptoms  Severity of symptoms  Frequence of symptoms  Period of time between the last episode EXERCISE  Triggers: EXERCISE, drugs, alcohol…  Ingested foods MEDICAL HISTORY is essential: EXERCISE-INDUCED ANAPHYLAXIS

14. Skin Prick Tests Specific IgE (CAP) for native and recombinant allergens Food Challenges: Only food challenge (to rule out classical food allergy) Only exercise challenge (to rule out classical exercise-induced anaphylaxis – rare!) Food challenge + exercise challenge (+ ASA challenge) (to confirm the diagnosis) EXERCISE-INDUCED ANAPHYLAXIS DIAGNOSIS MEDICAL HISTORY is essential:

15. THERAPY AND RECOMMENDATIONS FOR PATIENTS To avoid to do exercise after 4-6 hours after the ingestion of foods SELF-INJECTABLE EPINEPHRINE EXERCISE-INDUCED ANAPHYLAXIS