II. Definition

  1. Allergic symptoms in response to Exercise

III. Epidemiology

  1. On average, symptoms persist 10 years before diagnosis is made

IV. Types

  1. Cholinergic Urticaria
    1. Micropapular hives
      1. Erythematous halo with central 2 to 5 mm Papule
    2. Exaggerated response to Body Temperature
    3. Associated with rise in plasma histamine
  2. Variant Exercise-Induced Anaphylaxis
    1. Lesions similar to CholinergicUrticaria
    2. May progress to Anaphylaxis
  3. Food-Dependent Exercise-Induced Anaphylaxis (FDEIA)
  4. Classic Exercise-Induced Anaphylaxis
    1. Precipitated by Exercise at any level
    2. Criteria
      1. Angioedema or Urticaria and
      2. Airway obstruction and
      3. Hypotension
    3. Associated symptoms
      1. Generalized Pruritus
      2. Choking Sensation
      3. Gastrointestinal colic
      4. Nausea
      5. Headache
      6. Wheezing
    4. Course
      1. Duration: 30 minutes to 4 hours after Exercise

V. Predisposing factors

  1. Family History
  2. Atopic history
  3. Specific food intakes prior to Exercise (in some cases any food before Exercise)
    1. Alcohol (common)
    2. Aspirin (common)
    3. NSAIDs (common)
    4. Seafood
    5. Celery
    6. Wheat
    7. Cheese

VI. Diagnosis: CholinergicUrticaria

  1. Passive Warming Test
    1. Increase core Body Temperature >0.5 C or >0.9 F
      1. Patient immerses in warm water or
      2. Raise Ambient Temperature
    2. Interpretation
      1. CholinergicUrticaria: Plasma histamine increases
      2. Exercise-Induced Anaphylaxis: No histamine increase
  2. Methacholine Skin Test
    1. Methacholine 100 units in saline injected intradermal
    2. Positive test induces micropapular hives
    3. Test Sensitivity: 33%
    4. High Test Specificity

VII. Diagnosis: Exercise-Induced Anaphylaxis

  1. Exercise challenge test with treadmill or Exercise bike
  2. Negative test does not rule out condition
  3. Emergency equipment must be available
    1. Epinephrine ready for Subcutaneous Injection
    2. Intubation equipment
    3. Oxygen Source
    4. Advanced Cardiac Life Support Cart

VIII. Management: General Measures

  1. Activity modification
    1. Exercise with partner with BLS training (and who carries an Epinephrine Auto-Injector)
    2. Avoid exacerbating factors before Exercise
      1. Do not Exercise for 4-6 hours after eating
      2. Avoid Aspirin or NSAIDs prior to Exercise
      3. Avoid exercising during Menses
  2. Self-Management of acute episodes
    1. Subcutaneous Epinephrine (Epi-Pen) always available
    2. Stop Exercise with onset of symptoms (early stopping may prevent full Anaphylaxis)
    3. Administer Epi-pen for first signs of Anaphylaxis
      1. Flushing
      2. Pruritus
    4. Pursue immediate medical care for progressing signs

IX. Management: Medications

  1. Acute episode
    1. See Anaphylaxis
    2. See Urticaria
  2. Prevention
    1. Review if medication banned for competitive athlete
    2. Antihistamines
      1. Sedating Antihistamines: Hydroxyzine (Atarax)
      2. Non-Sedating Antihistamines: Allegra, Zyrtec
    3. Other potential agents
      1. Cromolyn Sodium (Intal)
      2. Leukotriene Antagonist (Singulair, Accolate, Zyflo)

X. References

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Exercise anaphylaxis (C0344183)

Concepts Disease or Syndrome (T047)
SnomedCT 241952007
Dutch door inspanning ontstane anafylaxe
German Anaphylaxie bei Belastung
Italian Anafilassi indotta dallo sforzo
Portuguese Anafilia induzida pelo exercício
Spanish Anafilaxis inducida por ejercicio, anafilaxia inducida por ejercicio (trastorno), anafilaxia inducida por ejercicio, anafilaxis inducida por ejercicio (trastorno), anafilaxis inducida por ejercicio
Japanese 運動誘発アナフィラキシー, ウンドウユウハツアナフィラキシー
French Anaphylaxie déclenchée par l'effort
Czech Anafylaxe vyvolaná cvičením
English anaphylaxis exercise, anaphylaxis exercise induced, exercise anaphylaxis, exercise-induced anaphylaxis, Exercise anaphylaxis, Exercise-induced anaphylaxis, Exercise anaphylaxis (disorder)
Hungarian Terhelés indukálta anaphylaxia

Ontology: exercise-induced urticaria (C2063523)

Concepts Disease or Syndrome (T047)
English exercise-induced urticaria (diagnosis), exercise-induced urticaria