Food-Dependent Exercise-Induced Anaphylaxis to Chickpea in a 17-Year-Old Female: A Case Report
J Med Case Reports. 2015;9(186)
- Abstract and Introduction
- Case Presentation
- Discussion
- Conclusions
- Consent
Abstract and Introduction
Abstract
Introduction: Food-dependent exercise-induced anaphylaxis is a subtype of anaphylaxis and, although rare, it is an important condition to be familiar with as it can ultimately lead to death.Case presentation: We present a case of food-dependent exercise-induced anaphylaxis in a 17-year-old white girl due to chickpea. She had a history of anaphylaxis after eating crackers and hummus before exercising. Skin prick testing and serum-specific immunoglobulin E level confirmed chickpea to be the causative allergen.
Conclusions: This case demonstrates the challenge in identifying specific causative food allergens when foods are eaten in combination, when the food is processed, and when cross-reactivity is possible. These challenges add complexity to a condition that is already rare and unfamiliar to some health care providers. We hope that this case will serve as an important reminder that although rare, food-dependent exercise-induced anaphylaxis exists and making a diagnosis can lead to life-saving preventative strategies. As legumes are not a common food associated with food-dependent exercise-induced anaphylaxis, this will add to our current knowledge base in the field of allergy.
Introduction
Anaphylaxis is a systemic allergic reaction that is rapid in onset and has the potential to cause death.[1] Once diagnosed, avoidance of allergen and carrying an epinephrine auto-injector is recommended.[2] Most anaphylactic reactions are immunoglobulin E (IgE) mediated and the major triggers include food, medication, venom, latex, exercise, and transfusions.[3] It is reported that anaphylaxis affects at least 1.6% of the general population.[4]Food-dependent exercise-induced anaphylaxis (FDEIA) is a subtype of anaphylaxis and is rare.[5] FDEIA is more commonly described in adolescents and adults versus younger children.[6] The condition is characterized by anaphylaxis that develops in association with physical exertion and ingestion of a causative food within a certain timeframe. In an analysis of 167 Japanese cases of FDEIA, 80% of the patients developed symptoms within 2 hours of eating the causative food.[7] Neither the food allergen nor exercise alone triggers anaphylaxis. Typical symptoms seen in FDEIA include skin manifestations (urticaria, erythema, edema, and pruritus), dyspnea, abdominal pain, and fatigue.[8] The pathogenesis is not fully understood yet. Based on skin prick testing (SPT) and specific IgE results for causative foods, an IgE mechanism is likely. The exact mechanism that results in a transient disruption in immune tolerance to causative foods is not known and different theories exist.[9] It is thought that exertion triggers physiological change that enhances absorption of undigested, immunoreactive forms of allergen from the gastrointestinal tract. Specific co-triggers such as non-steroidal anti-inflammatory drugs (NSAIDS), aspirin, extreme temperatures, a second food, menstruation, and stress, have also been theorized to aid in the development of FDEIA.[5], [6] The primary foods reported to trigger FDEIA are wheat and shellfish,[10] although in Europe tomatoes appear to be more common in FDEIA than wheat.[6] A variety of other foods have been identified in FDEIA including vegetables, fruits, nuts, egg, mushrooms, rice, and meat.[7]
Diagnosis relies on a thorough history to identify food allergen exposure, along with the combination of exercise and possible co-triggers. SPT and specific IgE levels can reveal the food allergen(s) and exclude other suspected allergens. A positive oral-food exercise challenge would further confirm a diagnosis, but is unnecessary if the history is suggestive and SPT and/or IgE levels are consistent.[5]
We present a case of FDEIA to chickpea in a 17-year-old girl with a convincing clinical history, positive SPT to fresh chickpea and hummus extract, along with an elevated serum-specific IgE level to chickpea. To the best of our knowledge, this is the first case demonstrating FDEIA to chickpea in an adolescent. This case describes the challenge in identifying specific causative food allergens when foods are eaten in combination, when the food is processed, and when cross-reactivity is possible.
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J Med Case Reports. 2015;9(186) © 2015
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