Food dependant exercise induced anaphylaxis a retrospective study from 2 allergy clinics in Colombo, Sri Lanka

de Silva et al. All Asth Clin Immun (2015) 11:22 DOI 10.1186/s13223-015-0089-6 Open Access CASE REPORT Food dependant exercise induced anaphylaxis a retrospective study from 2 allergy clinics in Colombo, Sri Lanka Nilhan Rajiva de Silva1*, Wasala Mudiyanselage Dhanushka Kumari Dasanayake1, Chandima Karunatilleke1 and Gathsauri Neelika Malavige2 Abstract The aetiology of anaphylaxis ranges from food, insect venom, drugs and various chemicals. Some individuals do not develop anaphylaxis with the offending agent unless ingestion is related temporally to physical exertion, namely food dependent exercise induced anaphylaxis (FDEIA). The foods implicated are wheat, soya, peanut, milk and sea food. A retrospective study on patients with FDEIA from two Allergy clinics in Sri Lanka from 2011 to 2015 is reported. Patients were selected who fulfilled the following criteria: clinical diagnosis of anaphylaxis according to the World Allergy Organization (WAO) criteria, where the onset of symptoms was during exertion, within 4 h of ingesting a food, the ability to eat the implicated food independent of exercise, or exercise safely, if the food was not ingested in the preceding 4 h and an in vitro (ImmunoCap serum IgE to the food) or in vivo (skin prick test) test indicating evidence of sensitivity to the food. There were 19 patients (12 males: 7 females). The ages ranged from 9 to 45 (mean 22.9, median 19 years). Eight patients (42.1%) were in the 9–16 age group. Those below 16 years had a male:female ratio of 3:5, while for those above 16 years it was 9:2. Wheat was the only food implicated in FDEIA in all patients and was confirmed by skin prick testing, or by ImmunoCap specific IgE to wheat or ω − 5 gliadin. All patients had urticaria, while 5/19 (26.3%) had angioedema of the lips. Fifteen patients (78.9%) had shortness of breath or wheezing, while 8 (42.1%) had lost consciousness. Nine patients (47. 3%) had hypotension. Fourteen (73.6%) of our patients had severe reactions, with loss of consciousness or hypotension, while 5 (26.3%) had symptoms related to the gastrointestinal tract. One patient developed anaphylaxis on two occasions following inhalation of ganja, a local cannabis derivative along with the ingestion of wheat and exertion. Wheat is the main food implicated in FDEIA in Sri Lanka. A local cannabis derivative, ganja has been implicated as a cofactor for the first time. Keywords: Anaphylaxis, FDEIA, Wheat, Food allergy, Exercise Background Anaphylaxis is a potentially fatal, systemic hypersensitivity reaction [1]. The aetiology of anaphylaxis ranges from food, insect venom, drugs and various chemicals. In some cases of anaphylaxis, the individual does not develop anaphylaxis with the offending agent unless ingestion is related temporally to physical exertion [2]. The initial case report described a patient who developed *Correspondence: 1 Department of Immunology, Medical Research Institute, Colombo 08, Sri Lanka Full list of author information is available at the end of the article anaphylaxis during exertion after ingesting shellfish [3]. This condition was termed food dependent exercise induced anaphylaxis (FDEIA) [4]. A number of food items have been implicated in FDEIA such as wheat, soya, peanut, milk and sea food [5]. Anaphylaxis following exertion, without concomitant intake of food was also described, termed exercise induced anaphylaxis (EIA) [6]. EIA constitutes 5–15% of all cases of anaphylaxis [5]. A third or half of EIA are due to FDEIA [2]. In FDEIA, anaphylaxis develops only if a specific food, or in some instances, any food, is ingested up to 4 h before exertion. In some instances, ingestion of the food may be after exertion [2]. Ingesting the food without © 2015 de Silva et al. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. de Silva et al. All Asth Clin Immun (2015) 11:22 exertion, or exertion in the absence of preceding ingestion of food does not lead to symptoms. Although the exact pathogenesis of FDEIA is not clear, changes in serum osmolality and the pH, changes in permeability of the intestinal epithelium and blood flow re distribution are thought to play a role [7]. It is believed that co factors may influence the process in two ways, by either increasing bioavailability of the food by increasing intestinal permeability or by reducing the threshold for mast cell degranulation [8]. Exercise, alcohol and certain drugs have been shown to increase the intestinal absorption of allergens, by inducing a leakage of the intestinal barrier [8], and exercise provocation has shown a dose dependent reactivity [9]. It is well documented that exercise may reduce the threshold for mast cell and basophil activation, even though the exact mechanism is still unclear [8]. Increased plasma osmolality, or activation of intestinal tissue transglutaminase (tTG) have been postulated. An increase in IL 6 (increased 50–100 times in marathon runners) upregulates tTG, which then causes aggregation of ω − 5 gliadin, a wheat component implicated in FDEIA. The aggregated product can more efficiently cross link Fcε receptors on mast cells and basophils [10]. FDEIA has been described in the West [11], and in South East Asia, including Japan [12, 13], Korea [14], Singapore [15] and Thailand [16]. Here we report for the first time, a series of cases of FDEIA due to wheat allergy in Sri Lanka. Case presentations Methods This is a retrospective review of patients diagnosed at 2 allergy clinics in Colombo, one at the Medical Research Institute (RdeS), and the other at Asiri Surgical Hospital (GNM) between 2011 and 2015. FDEIA was diagnosed if the patients fulfilled the criteria presented in Table 1 [1–3]. Case records were analysed, including clinical history and results of skin prick testing and in vitro testing for the implicated food. As this is a retrospective study, ethical clearance was obtained to collect data from the Ethics Committee of the Medical Research Institute, Colombo. However, the patients were traced and written informed consent was obtained for publication. Page 2 of 7 Results Nineteen patients were diagnosed with FDEIA. All had wheat dependent exercise induced anaphylaxis. No other food was identified to cause FDEIA in the two clinics during the study period, even though two patients, in addition to wheat dependent exercise induced anaphylaxis, developed anaphylaxis without ingesting wheat on 1 and 2 occasions, respectively (Table (...truncated)