Exercise-induced urticaria, cholinergic urticaria, and Kounis syndrome

Physical exercise may provoke the onset of clinical symptoms that are usually associated with an allergic reaction. Distinct forms of recognized physical allergies are exercise-induced anaphylaxis (EIA), food-dependent EIA cholinergic urticaria, exercise-induced bronchospasm, and rhinitis. In a report, the authors described a 26-year-old male with 3-year history of exercise-induced rash accompanied by flushing, feeling unwell and warm, eyelid angioedema, pruritus, and headache. His symptoms were relieved with discontinuation of exercise. No history of any specific food, drink, or medication intake before exercise was apparent, but the patient described nonspecific allergic rhinitis episodes to dust. He subsequently underwent extensive investigation including skin prick tests to numerous food items including meat and vegetables as well as specific immunoglobulin E (IgE) for wheat, most of which proved to be negative. The only positive skin prick tests were for mites and grasses. His symptoms subsided with antihistamine and antileukotriene therapy with montelukast that enabled him to start exercising again without symptoms. EIA is an unpredictable and potentially fatal syndrome affecting pediatric individuals also with a prevalence of 0.048% and can seriously damage the patient’s quality of life. This condition may occur independently or may require the ingestion of a food allergen either pre- or post-exercise. Atopic individuals are specifically prone to this condition. Therefore, this report raises several important questions concerning the etiology, pathophysiology, associations and treatment of EIA.