D2.304 - Allergy and Exercise: A Sporting Challenge

A 19-year-old male patient experienced four reactions within 12 months characterized by pruritus, angioedema, urticaria, dizziness, and one episode of syncope of unclear origin. The reactions occurred after consumption of various plant-based foods in combination with physical activity. The meals included: (1) spaghetti with feta cheese, tomatoes and olives as well as nougat bites with cow’s milk, (2) bread with strawberry jam, (3) oven-baked vegetables with ciabatta, and (4) tortelloni with cheese and spinach filling. One to two hours after eating, the patient either went jogging or cycled through the city at a relaxed pace. Two reactions occurred during jogging and two after cycling.

Past medical history included mild intermittent allergic rhinoconjunctivitis due to tree pollen and a peanut allergy (first diagnosed at the age of seven, with strict avoidance since then).

Skin prick testing showed sensitization to, among others, birch pollen, peach, wheat flour, hazelnut and peanut. Measurement of specific IgE using the multiplex allergy test ALEX2 revealed sensitization to several non-specific lipid transfer proteins (nsLTP), including peach (Pru p3), wheat (Tri a14), maize (Zea m14), kiwi (Act d10), apple (Mal d3), strawberry (Fra a3), grape (Vit v1) and hazelnut (Cor a8). No sensitization to wheat omega-5-gliadin (Tri a19) was detected. Baseline serum tryptase was within the normal range at 3.5 µg/L.

During a controlled challenge test, anaphylaxis (pruritus, palmar erythema, angioedema, urticaria, hypotension) occurred after ingestion of 64 g of wheat gluten in combination with 20 ml of 95% alcohol, 1000 mg aspirin, and 20 minutes of jogging. Serum tryptase increased from 3.5 to 60.5 µg/L.

Based on these findings, the diagnosis of LTP-/Tri a14-mediated wheat-dependent exercise-induced anaphylaxis (WDEIA) with suspected LTP syndrome was established. Omega-5-gliadin–negative LTP-/Tri a14-mediated WDEIA is a rare condition (3.7% in the WDEIA cohort at the Technical University of Munich).

This case highlights the importance of challenge testing with cofactors and underscores that both WDEIA and LTP syndrome should be considered in patients presenting with reactions to various plant-derived foods in combination with physical activity.