After gorging on a “beautiful” custard donut one day, Jay (full name withheld on request), a 23-year-old chess coach and biochemist from Melbourne, Australia, decided to take a short walk along with his sister. Twenty minutes into the walk, he suffered itchiness, a sign of severe allergy after his exercises. “It felt like there were bugs under my clothes,” Jay tells Happiest Health while describing the first-ever episode of food-dependent, exercise-induced anaphylaxis or FDEIA (a life-threatening allergic reaction) that he experienced.
“I complained to my sister, saying, ‘There is some sort of bug in my clothes biting me everywhere,’” he says. “But then it started at my feet and ankles. I felt myself feel ‘sick’ and my blood pressure dropped dramatically. However, I was also panicking, so I ran home out of fear, and by the time I got home, my lips were getting hives all over them, too.”
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Jay showered soon after he returned home and applied anti-itching cream on himself. “I just waited and admittedly cried until it faded one hour later,” he says.
After this episode, Jay started maintaining a food journal in which he would log all food intake and reactions he experienced.
Soon after, he consulted an allergy specialist who, after a thorough examination of Jay’s clinical history and food journal, recommended he take a radioallergosorbent test (RAST), a type of blood test that aims to detect antibodies in the blood that indicate an allergy to specific substances.
Jay’s diagnosis confirmed that he was allergic to wheat/gluten and that consumption of these substances, followed by even a mild physical activity, including something as simple as walking up to his room, induced a severe allergic reaction.
“Any combination of gluten and exercise induces a severe reaction — even a small bowl of pasta and walking up to my room can cause it. But it can also happen from stress — like it did on a first date with my now girlfriend of two years, after eating pizza,” he says.
Today, Jay carries epinephrine auto-injectors (a medical device used to treat severe allergic reactions) and antihistamines (medication commonly used to treat allergies) everywhere and has completely removed gluten from his diet.
Dr Zareen Mohamed, consultant allergy and asthma specialist, Dr Mehta’s Hospitals, Chennai, and author of the paper ‘A case of wheat-dependent exercise-induced anaphylaxis’ published in the Indian Journal of Allergy, Asthma & Immunology, says that food-dependent, exercise-induced anaphylactic reactions occur in cases where a person consumes the allergy-triggering food and then engages in physical activity.
“In FDEIA, when you take the food, you don’t get an allergy but when you engage in any physical activity after taking these foods, it could cause an anaphylactic reaction,” she says.
In this type of rare allergic reaction, which is different from food-induced anaphylaxis and exercise-induced anaphylaxis, the symptoms are caused by both consumption of the food and physical activity afterwards, and not by one of these alone.
Jay says he was not aware of the condition before his diagnosis. “It was a huge surprise,” he says. “In fact, it took a year and a half to both get on top of and figure out.”
Dr Mohammed recalls a case she handled in 2014, of a 25-year-old woman who showed up at the hospital after a history of repeated episodes of anaphylaxis. Close examination of her clinical history revealed that all the episodes of anaphylaxis were linked to physical activity or exercise after eating breakfast that contained wheat.
While the first episode that occurred in 2010 was linked to a morning walk after consuming breakfast, all subsequent episodes occurred by walking immediately after consuming wheat chapattis, wheat bread and prawns.
“In this case, there was a clear-cut history of the same food causing repeated reactions. She was asked to avoid wheat products. She also had some underlying hormonal disturbances that were causing this,” says Dr Mohammed.
In addition to eliminating these foods from her diet, the patient was also asked to avoid exercising or walking one hour after eating, advised to carry injectable epinephrine everywhere with her and was prescribed mast cell (tissue cell of immune systems) stabilisers.
Dr Mohammed says that while wheat is the food that is most commonly associated with FDEIA, she has also seen cases where it has been caused by physical activity following consumption of nuts and spinach.
“The 25-year-old woman who presented with wheat-dependent, exercise-induced anaphylaxis was the first case I handled. After that, I saw several such cases, around three to four cases per year,” she says.
A study titled ‘Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review’ published in the Journal of Allergy and Clinical Immunology, also found that wheat was the most common allergen in these cases while running was the physical activity that most triggered allergic reactions in people after consumption of food. As per the study, the duration between exercise and onset of symptoms ranged from five minutes to five hours.
Dr Sandeep Patil, chief intensivist and physician, Fortis, Kalyan, Mumbai, says that FDEIA is a rare entity and some of the common symptoms include:
- Itching
- Hives
- Breathing trouble
- Loose motion
- Vomiting
Causes of FDEIA
“These are certain theories as to why the person develops a pro-inflammatory response after exercise while they are able to tolerate the food otherwise,” says Dr Mohammed.
Dr Nikhil Paul, assistant professor of Emergency Medicine at Sree Gokulam Medical College, Thiruvananthapuram, says, “In any allergic reaction, it is the release of histamine that leads to symptoms like flushing sensation, itching, hives and breathing trouble.”
Dr Mohammed says although a cause for FDEIA has not been established yet “one of the theories is that an allergic reaction occurs due to an alteration in the plasma (liquid component of the blood) pH when one undertakes strenuous physical activity, triggering the body’s mast cells.”
Dr Patil says, “Mast cells are part of the body’s defence system. They release histamines and other cytokines, inflammatory markers in response to an allergen. An allergen could be anything – from food to chemicals. When the person gets exposed to that allergen, the mast cells start secreting histamine which is released into circulation and this leads to the anaphylactic symptoms.”
Dr PC Kathuria, chest physician and allergy immunotherapy, critical care specialist, National Allergy Centre, New Delhi, who has handled cases of FDEIA where chia seeds, wheat and fish combined with exercise triggered severe allergic reactions, says that while the exact mechanism behind FDEIA is not known, the proposed mechanism is that, during exercise, the Omega-5-gliadin (a group of proteins found in wheat) component present in the wheat has higher affinity for cross-linking with mast cells, causing their degranulation and release of vasoactive mediators (histamine).
Treatment of FDEIA
“A very detailed investigation and analysis is required when somebody presents with anaphylaxis,” says Dr Mohammed. In all anaphylaxis cases, you must find out if the person has any autoimmune disorders or any malignancies or some underlying infections first, she adds.
“We must examine the patient’s clinical history thoroughly,” she says.
Dr Mohammed says that in cases of FDEIA, one can undergo a food challenge test where a little quantity of the suspected trigger food is consumed, and some physical activity is undertaken to see if it induces an anaphylactic reaction. The test must be conducted in a controlled setting, in a hospital or clinic.
Dr Kathuria says that people diagnosed with FDEIA must have knowledge of the emergency action plan in case of anaphylaxis regarding self-administration of adrenaline/ epinephrin.
“Treatment involves avoidance of suspected food and exercise for four to six hours after the food trigger and also of the co-factors such as alcohol, drugs like NSAIDS (non-steroidal anti-inflammatory drugs), beta blockers and ACE inhibitors (medications to reduce blood pressure),” says Dr Kathuria.
Describing how he now deals with a typical episode of FDEIA, Jay says, “I take antihistamines first and remain as still as possible, and if it gets to my lips/throat, I may use epinephrin and call emergency services.”
“Luckily in my case, it’s just the life of a celiac (an immune reaction to consumption of gluten), with a little more anxiety and fear around exercising,” he says.
