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Indian Pediatr 2013;50: 249 |
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Exercise Induced Anaphylaxis
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Parveen Mittal and Shinu Singla
Department of Pediatrics, Government Medical College,
Patiala 147 001, Punjab.
Email: [email protected]
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We read the article on anaphylaxis due to red fire ant bite
by Parvat, et al. [1] with interest. They have
rightly reported that all the anaphylaxis due to red fire
ant bite is not rare but no reports are available from
India. Similarly Exercise induced anaphylaxis, which is a
recently described rare disorder, the first case described
in 1979 and about thousand cases reported in last 30 years,
has not been reported in Indian literature [2]. The typical
age of onset is adolescent to third decade of life. We
recently came across a case of exercise induced anaphylaxis
at the age of 6 years. In a 10-year retrospective study by
Sheffer, et al. [3], the average age of onset was 26
years.
A 6-year-old male child was referred to
us with complaint of episodes of dyspnea from last 2 months.
On investigations including chest X-ray and
echocardio-graphy, no cardiac and respiratory cause of
dyspnea was found. Patient was admitted for observation.
Patient’s weight was 15 kg and height 130 cm. Vitals were
stable. General physical examination and systemic
examination was normal. The child remained well in the ward
for 3 days. On 4 th
day, the child developed severe urticaria all over the body,
child was gasping for breath, holding his neck as if having
choking sensation. On examination, patient’s eyes were
congested. Facial flushing, cutaneous erythema and multiple
urticarial lesions about 10-15 mm in size were present over
whole body. Patient’s pulse was 120/min, respiratory rate
40/min severe labored breathing, and blood pressure 60/40mm
Hg. The child was irritable. On auscultation, bilateral
rhonchi were present. Immediate oxygen inhalation by
facemask and I/V fluids were started. Inj. Adrenaline S/C,
inj. Hydrocortisone I/V and inj. avil I/V were given. After
about one hour, respiratory distress settled and rash
disappeared. Patient recovered completely at the end of one
hour. Serum levels of IgA tissue transglutaminase was sent.
It turned out to be negative. On asking the parents, they
told us that the entire episode was provoked by running. On
further questioning the mother, she told that from last 2
months, the child had repeated episodes of breathing
difficulty associated with facial flushing and urticaria
which were precipitated by running or excessive crying. As
per mother, previous episodes were mild in severity.
Cessation of physical activity results in immediate
improvement of symptoms but the child never recovered
completely. There was no relation of these episodes with
food intake and environmental temperature.
From history and examination, we
diagnosed this case as exercise induced anaphylaxis. More
than 1000 cases have been documented over past 30 years,
with exercise induced anaphylaxis accounting for about 7-9%
of all anaphylaxis cases [2]. Cutaneous mast cell
degranulation and elevation of plasma histamine and
trypticase has been documented in exercise induced
anaphylaxis. A large subset of patients will not develop
anaphylactic symptoms with exercise unless they have
ingested certain food groups a few hours before exertion.
Food dependent exercise induced anaphylaxis has a prevalence
of around 0.02 % [4]. The food groups most commonly
implicated include wheat products (around 60% cases) [5],
soymilk, peanuts, shellfish, corn, garlic, rice, celery,
cheese, alcohol, tomato, peaches, vegetables.
There are other factors which has a clear
influence on the development of anaphylaxis. Exercise
induced anaphylaxis may occur in extremes of temperature
(for instances, in athletes with cholinergic urticaria who
exercise in the heat, or in athletes with cold induced
urticaria who exercise in the cold). Treatment of exercise
induced anaphylaxis consist of immediate stabilization
geared toward the anaphylaxis response with epinephrine and
antihistamine. Due to potentially fatal nature of disease,
clinician should be aware of its clinical features and
appropriate management.
References
1. Havaldar PV, Patil SS, Phandnu C.
Anaphylaxis due to Red Fire ant bite. Indian Pediatr.
2012;49:237-8.
2. Castells MC, Horan RF, Sheffer AL.
Exercise induced anaphylaxis (EIA). Clin Rev Allergy Immunol.
1999; 17: 413-24.
3. Shadick NA, Liang MH, Parttridge AJ,
Bingham C, Wright E, Fossel AH, et al. The natural
history of exercise induced anaphylaxis: survey results from
a 10 year follow-up study. J Allergy Clin Immunol.
1999;104:123-7.
4. Alihara 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.
5. Schwartz LB, Delgado L, Craig T, Bonini S, Carlsen KH,
Casale TB, et al. Exercise induced hypersensitivity
syndromes in recreational and competitive athletes: a
PRACTALL consensus report (what the general practitioner
should know about sports and allergy). Allergy.
2008;63:953-61.
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