A 16-Year-Old Girl With Full-Body Rash, Dyspnea, and Swelling

Peter Huynh, MD

Disclosures

January 19, 2022

Discussion

Exercise-induced anaphylaxis (EIA) is a rare disorder in which anaphylaxis occurs after physical activity.[1] The symptoms may include pruritus; hives; flushing; wheezing; and gastrointestinal involvement, including nausea, abdominal cramping, and diarrhea. If physical activity continues, patients may progress to more severe symptoms, including angioedema; laryngeal edema; hypotension; and, ultimately, cardiovascular collapse. Cessation of physical activity usually results in immediate improvement of symptoms. The typical age of onset of EIA is from adolescence to the third decade of life.

Patients with EIA often have prodromal symptoms that alert them to impending severe symptoms if physical activity continues.[2] Prodromal symptoms may include a feeling of fatigue, generalized warmth and pruritus, and cutaneous erythema. These early symptoms are followed by typical urticarial lesions and angioedema that can progress to gastrointestinal symptoms, laryngeal edema, and/or vascular collapse.

Symptoms may begin at any stage of exercise. Although cessation of the physical activity usually results in immediate improvement or resolution of symptoms, some patients may experience vascular collapse even after exercise cessation. The frequency of symptoms during exercise varies among patients with EIA. Most patients can exercise regularly and only occasionally experience attacks.

Vigorous forms of physical activity, such as jogging, tennis, dancing, and bicycling, are more commonly associated with EIA, although lower levels of exertion (eg, walking, yard work) are also capable of triggering attacks. In a long-term follow-up study, the physical activity most often associated with exercise-induced anaphylaxis was jogging.[3] Other reports have implicated running, soccer, raking leaves, shoveling snow, and horseback riding.[4]

EIA attacks may not be consistently elicited by the same type and intensity of physical activity in the same patient. Such cofactors as foods, alcohol, temperature, drugs (eg, aspirin, other nonsteroidal anti-inflammatory drugs), humidity, seasonal changes, and hormonal changes are important in the precipitation of attacks.

A distinct subset of EIA is food-dependent EIA (FDEIA), in which anaphylaxis develops only if physical activity occurs within a few hours after eating a specific food. Neither food intake nor physical activity by itself produces anaphylaxis.[5] The foods most commonly implicated in FDEIA include wheat, shellfish, tomatoes, peanuts, and corn.[6] However, the disorder has been reported with a wide variety of foods, including fruits, seeds, milk, soybean, lettuce, peas, beans, rice, and various meats. One case report described a patient who developed symptoms of anaphylaxis only after simultaneous ingestion of two foods (wheat and umeboshi) before exercise.[7] In the nonspecific form of FDEIA, eating any food before exercise induces anaphylaxis.[8]

Inhalant allergens have also been implicated in EIA. In a case report, a 14-year-old boy presented with severe EIA after ingestion of Penicillium mold-contaminated food and running at school.[9] In another case report, a 16-year-old girl presented with EIA after ingestion of wheat flour contaminated with storage mites.[10]

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