Two cases of food-dependent exercise-induced anaphylaxis with different culprit foods
A 14-year-old Palestinian female middle school student seen initially in the allergy clinic on October 2009. She described frequent attacks of itchy hives, swelling of lips, and eyelids. They were followed by dyspnea, wheezing, and dizziness spills. She gave history of four attacks over the last year. In all the attacks, her symptoms appeared during physical exertion immediately following the ingestion of her dinner that usually contains wheat bread, cheese, and eggs. Surprisingly, she could tolerate these foods if it was not followed by exercise. Moreover, her symptoms never occurred if a meal did not precede performing the exercise activity. Her last attack was severe and occurred while jogging and running at the backyard immediately after having a slice of vegetarian pizza for which she attended the emergency room (ED). She gave history of not taking any medication specifically nonsteroidal anti-inflammatory drugs (NSAIDs) before having exercise. Also, the attacks were not related to her menstruation. Review of her past medical history and family history were noncontributory. In the ED, she was treated for anaphylaxis with intramuscular adrenalin and intravenous antihistamine, hydrocortisone, and fluids. And she was instructed to avoid eating cheese and eggs. In the allergy clinic, her physical examination was non remarkable and dermographism test was negative. Her baseline serum tryptase was normal. The serum tryptase was not checked in the ED during the attacks. The allergy skin prick testing for common foods showed a positive reaction to only wheat. A supervised graded oral challenge with wheat at rest was performed and was tolerated without any consequences. She was instructed to avoid any exercise for 4 h after ingestion of food, particularly the wheat. Over the last 2 years of regular follow-up, she described no single episode of anaphylaxis.