Antihistamine and sodium cromoglycate medication for food cold water exercise‐induced anaphylaxis

Food exercise-induced anaphylaxis (FEIA) is an uncommon but well described immunoglobulin (Ig) E-mediated reaction potentially causing severe anaphylaxis (1) after ingestion of a specific food, most often wheat flour, exclusively when followed by exercise (2). The patient reported here suffered from FEIA, exclusively when exercising in cold water. He is a 17-year-old man playing national league water-polo, swimming every day for at least 1 h. He was experiencing in the last 2 years monthly anaphylactic reactions ranging from diffuse urticaria to acute asthma when swimming up to 6 h after eating wheat. The reactions appeared in various swimming pools as well as in a lake (water temperature between 18 and 25 C) but not when doing other types of exercise (e.g. running) indoors or outdoors. Oral antihistamines alone failed to prevent the reactions but no reaction occurred on a wheat avoidance diet for 8 h prior to swimming. His medical history revealed polleninduced allergic rhinitis. He never suffered from atopic dermatitis, asthma or any type of physical urticaria, and had no sign of systemic disease. Skin prick tests showed sensitization to celery, nuts and various pollens (weed, rye and mugwort) and negative results for various cereals including wheat and soy. Serum-specific IgE (by UniCAP, Phadia, Uppsala, Sweden) were positive at 0.8 kU/l for wheat, 3.96 kU/l for rye, 1.22 kU/l for barley, 3.67 kU/l for maize and 1.69 kU/l for buckwheat flour. Basal serum tryptase level was normal. Further diagnostic work-up included food challenges without and with exercise as summarized in Table 1. The challenge tests were conducted in the morning, in a fasting state or 90 min after ingestion of 3.5 g of cooked wheat protein. The patient remained asymptomatic after running 20 min on a treadmill. After ingestion of wheat, the patient developed diffuse pruritus and urticaria on his trunk after 15 min of brisk swimming in the cold swimming pool (24 C). The challenge was stopped and the symptoms resolved spontaneously. Interestingly, no symptoms appeared in the warm swimming pool (31 C) after a similar effort. Diet was the major drawback for the patient s sport activity. Therefore, a protective treatment with oral antihistamine (fexofenadine, Telfast 360 mg, once a day; sanofi-aventis, Geneva, Switzerland) and oral sodium cromoglycate (Nalcrom 200 mg; sanofi-aventis) prior to every meal was started. The efficacy of this treatment was assessed by a negative wheat challenge followed by swimming in the cold water pool. Two weeks later, on protective medicine, the patient was progressively reintroduced to wheat without reaction. The food and exercise challenge tests demonstrated that our patient suffered from FEAI to wheat but exclusively in cold water with a temperature below 31 C, with a threshold between 25 and 31 C. Food exercise-induced anaphylaxis is usually manageable with avoidance diet only. However, restrictive diet or exercise avoidance can be difficult and impair quality of life, particularly in athletes. Cromoglycate, a mast cell stabilisator, was studied earlier in food allergy but failed to be effective in egg allergic patients (3). However, we could show that the addition of antihistamine and cromoglycate abrogated the symptoms, allowing our patient to keep on his high level training programme while eating a nonrestricted diet. This confirms an earlier case report of a successful prevention of FEIA with sodium cromoglycate (4). Only larger trials could demonstrate if antihistamines combined with sodium cromoglycate could avoid restrictive diet in selected patients with this condition. P. A. Eigenmann has consulting arrangements with Phadia and is on the speakers bureau for Phadia, Trimedal, Milupa, UCB Pharma, Mead Johnson, Fujisawa, Novartis, Abbot and Essex. The other authors report no potential conflict of interest.