Exercise‐induced anaphylaxis in a marathon runner

Abstract

After completion of a marathon (26.2 mile running race), a 41‐year‐old woman presented to the medical tent complaining of hand swelling. She denied any hand pain or numbness, diarrhea, nausea, vomiting, or abdominal pain, but admitted to slight hoarseness. Whilst she denied shortness of breath at that moment, she had noted dyspnea out of proportion to her athletic activity during the first 3 miles of the marathon. Thereafter, she ran without respiratory discomfort. She also recalled hand swelling and dyspnea out of proportion to her activity during her marathon training, especially on warm and humid days. Similar lesions, but to a much milder degree, had developed during brisk walks. These lesions began within the first 15 min of exercise and were associated with pruritus. She admitted to eating, only occasionally, a banana before her runs. She denied developing lesions whilst experiencing sudden powerful emotions, taking hot showers, or eating hot foods. She had no other medical problems, except for depression, for which she took venlafaxine. The symptoms related to her running were unrelated to her venlafaxine intake. She began having the swelling many years before starting the medication and continued having the swelling after discontinuation of venlafaxine. She had no history of atopic dermatitis, but 2 years subsequent to this most recent episode, she had been diagnosed with atopic dermatitis by her primary medical physician. There was no family history of similar eruptions. Physical examination revealed diffuse swelling of both hands, including all digits, with mild, ill‐defined overlying erythema (Fig. 1). She had similar lesions on her feet and also had mild diffuse facial swelling, but did not have pronounced lip, tongue, or eyelid swelling. The swelling largely resolved within 4 h. 1 Diffuse swelling involving the hand and all digits with mild overlying erythema. Notice the constriction of the digit caused by the runner's wedding ring Exercise‐induced anaphylaxis was diagnosed. The patient continues to have similar eruptions with exercise, but has refused treatment with antihistamines or epinephrine.

Skin manifestations of running

“…4,19,20,26,40 Vibratory angioedema is a rare form of physical urticaria that seems to occur with increased frequency in people who also have cholinergic urticaria. 41,42 Transient erythema and wheals form at the site of the vibration secondary to intraepidermal or intercellular edema and increased blood flow. 43,44 Increased plasma histamine levels are present.…”

“…The first is activation of the alternative complement pathway and the second is IgE, lactate, or creatine phosophokinase mediated mast cell degranulation that results in increased serum levels of histamine. 5,41 Patients who are atopic and those with food allergies seem to be at highest risk. 19,36,37,40,46,48 Eating before exercise seems to predispose athletes to developing lesions.…”

“…50 In one study, 78% of individuals noticed that running induced their lesions. 5,41,47 Runners develop both cutaneous and systemic symptoms in EIA, with pruritus being a regular finding. 5,48 The reaction begins with sensation of cutaneous warmth, pruritus, and erythema, and progresses subsequently to urticaria or angioedema.…”

“…32,40,48 Angioedema may involve the face, hands, feet, tongue, lips, eyelids, and oropharynx and may persist for up to 72 hours. 4,40,41 Respiratory distress and vascular collapse may occur. 5,19,36,37,40,48 The symptoms typically begin within the first 5 minutes of exercise but may begin after exercise is complete.…”

“…5,19,36,37,40,48 The symptoms typically begin within the first 5 minutes of exercise but may begin after exercise is complete. 39,41 Runners should stop immediately if they suspect the onset of EIA. 19,27,40,45,48 The acute treatment of EIA focuses on vascular support and airway patency.…”