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Exercise-Induced Anaphylaxis and Urticaria ROBERT G Exercise-Induced Anaphylaxis and Urticaria ROBERT G. HOSEY, M.D., University of Kentucky School of Medicine, Lexington, Kentucky PETER J. CAREK, M.D., M.S., Medical University of South Carolina, Charleston, South Carolina ALVIN GOO, PHARM.D., Harborview Medical Center, Seattle, Washington In a select group of persons, exercise can produce a spectrum of allergic symptoms ranging from an erythematous, irritating skin eruption to a life-threatening ana- O A patient informa- phylactic reaction. The differential diagnosis in persons with exercise-induced der- tion handout on exer- cise-induced urticaria, matologic and systemic symptoms should include exercise-induced anaphylaxis written by the authors and cholinergic urticaria. Both are classified as physical allergies. Mast cell degran- of this article, is pro- ulation with the release of vasoactive substances appears to be an inciting factor vided on page 1374. for the production of symptoms in both cases. Exercise-induced anaphylaxis and cholinergic urticaria can be differentiated on the basis of urticarial morphology, reproducibility, progression to anaphylaxis and response to passive warming. Diagnosis is usually based on a thorough history and examination of the mor- phology of the lesions. Management of acute episodes of exercise-induced ana- phylaxis includes cessation of exercise, administration of epinephrine and anti- histamines, vascular support and airway maintenance. Long-term care may require modification of or abstinence from exercise, avoidance of co-precipitating factors and the prophylactic use of medications such as antihistamines and mast cell stabilizers. (Am Fam Physician 2001;64:1367-72,1374.) This article xercise-induced anaphylaxis is a seafood, celery, wheat and cheese.1,4,6 A variant exemplifies the AAFP distinct form of physical allergy has been described in which seven members 2001 Annual Clinical and, although rare, has been con- of the same family exhibited exercise-induced Focus on allergies, asthma and respiratory sistently described in the litera- cutaneous, respiratory and occasional vascu- 1 infections. ture since the 1970s. This disor- lar symptoms that were attributed to exercise- Eder is classically characterized by a spectrum induced anaphylaxis.7 of symptoms occurring during physical activ- Because symptoms may vary greatly, many ity that ranges from mild cutaneous signs to persons with exercise-induced anaphylaxis are severe systemic manifestations such as unaware of their condition. Similarly, because hypotension, syncope and even death. it is a relatively rare condition, it often goes Exercise-induced anaphylaxis has been undiagnosed. Primary care physicians should described at all levels of physical exertion and be able to recognize and manage exercise- during various athletic activities.2,3 In suscep- induced anaphylaxis and help patients prevent tible persons, ingestion of certain foods or the condition. medications before physical activity may be a predisposing factor. Aspirin and nonsteroidal Epidemiology anti-inflammatory drugs (NSAIDs) have been Since the original case description during the most frequently implicated medications.4,5 the 1970s, more than 1,000 cases have been Foods that have been implicated include described in the literature.8 Despite the poten- tial for full-blown anaphylaxis with exercise- induced anaphylaxis, only one death has been 9 In susceptible persons, ingestion of certain foods or medica- attributed to this disorder. This statistic sug- gests that many people with this condition tions before physical activity may be a predisposing factor have milder symptoms or are able to recognize for exercise-induced anaphylaxis. potentially life-threatening symptoms and limit their activity. Conversely, it is possible OCTOBER 15, 2001 / VOLUME 64, NUMBER 8 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1367 Anaphylaxis is a life-threatening syndrome Urticaria is characterized by pruritic, white or erythematous, that occurs in previously sensitized persons. nonpitting edematous plaques that change in size over time An anaphylactic reaction is manifested by res- piratory distress, with or without vascular col- and may coalesce to form larger “giant wheals.” lapse. Urticaria or angioedema may or may not accompany an anaphylactic episode. Urticaria, angioedema and anaphylaxis may that deaths caused by exercise-induced ana- have numerous causes that are often difficult phylaxis go unrecognized. Urticaria is a much to identify and are best classified by an etio- more recognized phenomenon, affecting 10 to logic mechanism (Table 1).11 20 percent of the population at some point in time.10 Urticarial responses occurring exclu- Exercise-Induced Disease Types sively during exercise are significantly less According to the literature, three distin- common. guishable exercise-induced urticarial disease types exist and include cholinergic urticaria, Definitions and Classification and classic and variant exercise-induced ana- Urticaria, angioedema and anaphylaxis may phylaxis (Table 2).11,12 occur separately or simultaneously. Urticaria, or “hives,”is characterized by pruritic, white or CHOLINERGIC URTICARIA erythematous, nonpitting edematous plaques. Cholinergic urticaria is a physical allergy These plaques change in size over time and manifested by small (2 to 5 mm) punctate may coalesce to form larger “giant wheals.” papules that are usually surrounded by an ery- Urticarial lesions are the result of capillary thematous halo. Often, however, only a pru- vasodilation followed by transudation of fluid ritic macular erythema covers an area of skin into the superficial dermis. Angioedema typi- 10 to 20 cm in diameter. Lesions usually begin cally involves accumulation of transudate in on the upper thorax and neck but may spread the deeper layers of skin and subcutaneous tis- to the entire body.10 sues, resulting in the development of thick, A single lesion typically resolves in 15 to 20 firm plaques. These lesions usually involve the minutes, although the episode that produces larynx, lips and gastrointestinal mucosa, many lesions may persist for several hours. although they may form anywhere on the skin. The lesions are known to occur in response to exercise, passive body warming and emo- tional stress. A rise in plasma histamine levels TABLE 1 has been demonstrated in symptomatic Etiologic Mechanisms of Urticaria/Anaphylaxis patients.3,13 If the inciting stimulus persists, the hives may coalesce and resemble angioedema, but vascular collapse is rare.11 The rightsholder did not Pulmonary symptoms often occur,3,11 but sig- grant rights to reproduce nificant changes on peak flow measurements this item in electronic and formal pulmonary function tests are not media. For the missing consistently reproducible.3,13 item, see the original print CLASSIC EXERCISE-INDUCED ANAPHYLAXIS version of this publication. Urticaria or angioedema with upper respi- ratory obstruction and hypotension precipi- tated by exercise are classified as classic exer- cise-induced anaphylaxis. Symptoms may 1368 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 64, NUMBER 8 / OCTOBER 15, 2001 Urticaria include generalized itching, a choking sensa- they may account for approximately 10 percent tion, gastrointestinal colic, nausea, headache of all cases of exercised-induced anaphylaxis.3,10 and wheezing. An episode may be precipitated by a variety of exercise activities at varying Pathophysiology degrees of exertion. Most commonly, jogging The specific etiology of exercise-induced and running have been described as the incit- anaphylaxis is unclear. Results from skin biop- ing activity.2,4 Activities such as dancing, vol- sies reveal that skin mast cell degranulation leyball, skiing and even yard work also have occurs during symptomatic attacks.14 It is been implicated. Symptoms typically last from likely that vasoactive mediators released by 30 minutes to four hours after the cessation of mast cells are responsible for the symptoms.2 exercise.2 Frequency of attacks may vary con- An increase in plasma histamine levels has siderably, from a single episode to several been demonstrated in patients with classic episodes annually. In addition, the episodes and variant forms of exercise-induced ana- are not consistently reproducible and thus are phylaxis and cholinergic urticaria.2,3,14 In unpredictable. They do, however, tend to addition, other products of mast cell degranu- decrease with time (the likely reason being lation, namely serum tryptase and leuko- that patients learn to avoid triggers).4 trienes, have been shown to be present at increased levels in symptomatic patients with VARIANT EXERCISE-INDUCED ANAPHYLAXIS exercise-induced anaphylaxis.15,16 The variant form of exercise-induced ana- An exaggerated cholinergic response to an phylaxis is the least common form. Like cholin- increase in body temperature (or to anxiety, ergic urticaria, variant exercise-induced stress or exercise) seems to be the cause of anaphylaxis produces small, punctate, erythe- cholinergic urticaria. Results of skin biopsies matous papules and is associated with of cholinergic urticarial lesions reveal histo- increased plasma histamine levels. However, logic characteristics identical with other forms the variant form is provoked only by exercise of urticaria. Specifically, neutrophils, mono- and may progress to anaphylaxis. Several cases nuclear cells and eosinophils are present in of the variant form have been described, and and around the walls of superficial subpapil- TABLE 2 Patterns
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