Wheat-Dependent, Exercise-Induced Anaphylaxis Can be Elicited without Exercise (And With Other Co-factors)

Rationale: Wheat-Dependent, Exercise-Induced Anaphylaxis (WDEIA) is a distinct clinical entity of wheat allergy characteristically elicited during exercise. We investigated if a clinical reaction could be elicited by intake of high amounts of gluten without exercise or by intake of gluten together with aspirin.

Methods: We prospectively investigated 30 patients (age 20.2 – 71.0 years) with a case-history of WDEIA. Diagnostic workup included specific-IgE (s-IgE), (ThermoFischer, Uppsala, Sweden): 26 positive to omega-5 gliadin (mean 12.0 kU/L [1.14-46.7]) and Skin Prick Test (SPT) with wheat flour (28 positive, mean 6.3mm [3.0-10.0]) and gluten (28 positive, mean 5.7mm [3.0-11.5]). Titrated oral challenge was performed with refined gluten (80g) at rest (n=30) and combined with exercise on a treadmill (n=30) or with aspirin 1000mg (n=14) on separate days.

Results: WDEIA was confirmed by challenge either at rest without cofactors (n=16) or with exercise as a co-factor (n=30). Threshold for the clinical reaction was lowered (mean 65 %) when oral challenge was combined with exercise (n=30) or with aspirin in (n=13). Nine of the 13 aspirin positive patients experienced lower threshold with aspirin than during exercise. Concomitant with a lower threshold, severity score (Sampson 2003) was higher in the majority of the patients with addition of exercise (n= 18) or aspirin (n=8).

Conclusions: Open oral gluten challenge at rest and/or in combination with exercise or aspirin is a sensitive test for diagnosing WDEIA. The reaction can be elicited at rest, rendering exercise and other cofactors such as aspirin facilitators lowering threshold and increasing severity of the reaction.