Food-dependent, exercise-induced anaphylaxis triggered by co-incidence of culprit food, physical effort and a very high dose of ibuprofen or menstruation: a case report

Food-dependent exercise-induced anaphylaxis (FDEIA) is defined as anaphylaxis resulting from co-incidence of ingestion of sensitizing food and physical activity, while any of those factors alone does not cause any adverse reactions [1–4]. A pathophysiological mechanism of FDEIA still remains not fully elucidated. An IgE-dependent mechanism triggered by ingestion of culprit food and confirmed by positive skin prick tests and/or specific IgE antibodies seems to be unquestionable. The role of physical exercise is not so obvious. It is considered that exercising increases absorption of nutrients from gastrointestinal mucosa into the systemic circulation [3, 4]. This assumption is supported by the fact that alcohol or nonsteroidal anti-inflammatory drugs (NSAIDs) are able to amplify an exercise-induced effect [5, 6]. In some individuals NSAIDs are able either to independently substitute exercise [7] or act as an ultimate third co-factor for exercise and food allergen in triggering FDEIA [5]. It has been also demonstrated that in some patients FDEIA symptoms occurr only during menstruation [8, 9]. We describe a patient in whom FDEIA symptoms occur only if exercising and ingestion of culprit food are accompanied by either a very high dose of NSAIDs or menstruation.
A 30-year-old female patient with no history of significant diseases (including allergy) reported three episodes of anaphylaxis within past 5 years (Table 1). Allergy diagnostics showed a total IgE concentration elevated to 170 IU/ml (n < 100 IU/ml) in the ELISA assay. Serum concentrations of C3-, C4-complement proteins and C1-esterase inhibitor were within normal limits. Skin prick-tests with common inhalant and food allergens (Allergopharma, Reinbek, Germany) were positive for grass, oak, rye, birch, beech, alder, hazel, mugwort and plantain pollens, as well as for house dust mites, cat and dog fur and mold spores of Aspergillus, Cladosporium and Alternaria. Food prick-tests were positive for hen egg, tomato, hazelnut, celery and chamomile. An intradermal test with autologous serum was negative. Physical tests: a rub test for dermographism, compression test and thermal test with ice cube were also negative. A standard exercise test [10] produced neither signs of anaphylaxis nor changes in spirometric values. Oral provocation tests with acetylsalicylic acid and ibuprofen up to the total cumulative doses of 1200 mg and 600 mg, respectively, were both negative and this excluded non-allergic...


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