What Is Exercise-Induced Anaphylaxis?

You might know that anaphylaxis — a severe allergic reaction — can occur in response to triggers such as nuts, insect bites, and certain medications. But physical activity can also induce anaphylaxis.

Known as exercise-induced anaphylaxis (EIA), this rare condition affects about 0.05 percent of people at some point in life. But EIA is serious and potentially life threatening, so it’s crucial to know how to recognize the symptoms and respond properly — and promptly.

Keep reading to learn more about EIA, including how food can be involved in these reactions and how to exercise safely with the condition.

EIA is a subgroup of anaphylaxis associated with physical activity, with or without another trigger. “In its classic form, someone goes for a jog in the park, for example, and along the way — oftentimes with strenuous exertion — they begin to develop features of anaphylaxis,” says Sebastian Lighvani, MD, a board-certified allergist at Northwell Health’s Lenox Hill Hospital in New York City. “That reaction can be anything from itching, hives, and swelling all the way to difficulty breathing and even anaphylactic shock.”

Signs of EIA can include any of the following, during or shortly after exercise:

Confusion
Difficulty breathing
Feeling dizzy or faint
Hives
Nausea and vomiting
Pale, clammy skin
Sudden cough or wheezing
Sudden sleepiness
Swelling of the throat, tongue, or upper airway, which can cause difficulty swallowing or a hoarse voice

If any of these symptoms starts, stop exercising right away. “You’re not going to fix this problem just by stopping exercise,” though, says Dr. Lighvani. You’ll also need to treat yourself with an injectable epinephrine device or nasal spray and get to the emergency room right away.

Sometimes, exercise alone can trigger EIA. “Cardio activities like running, dancing, or aerobic workouts are more commonly associated with it, but any exercise — including strength training or walking — can be a trigger in sensitive individuals,” says Inderpal Randhawa, MD, a board-certified allergist and pulmonologist and the founder of the Food Allergy Institute in Long Beach, California.

Eating a certain food prior to physical activity can also cause EIA. Known as food-dependent, exercise-induced anaphylaxis (FDEIA), this type of reaction accounts for 30 to 50 percent of all cases of EIA.

For people with FDEIA, eating the trigger food doesn’t lead to the allergic reaction on its own; it’s the combination of that food plus physical activity. The exact cause of FDEIA is not well understood, but some research suggests that the combination of food and physical activity may lead to a big release of mast cells, a type of white blood cell that is released during an allergic reaction. Another theory is that exercise diverts blood flow away from the digestive system and to the muscles, which then exposes the muscle tissue to the food allergen, causing the reaction.

Wheat is the most common food linked to FDEIA, but other common trigger foods include:

Alcohol
Apples
Beef
Eggs
Fish
Milk
Mushrooms
Nuts — specifically, peanuts and hazelnuts
Peaches
Pork
Shellfish
Tomatoes

You’ll need to see an allergist, who can begin the formal diagnostic process. They’ll review your medical history and may conduct food allergy testing or supervised exercise.

EIA can be difficult to diagnose, because it may not occur every time you exercise or eat a trigger food and then exercise. Also, the skin symptoms associated with EIA overlap with another condition called cholinergic urticaria, which can cause hives, itchiness, and redness during exercise or anytime your core body temperature increases (such as when taking a hot shower).

What sets these conditions apart is that EIA comes with a host of symptoms, says Lighvani. “It’s a multisystemic disorder, causing breathing issues, dizziness, [gastrointestinal] distress, while cholinergic urticaria is predominantly itchiness.”

You may always be at risk of a reaction during physical activity if you have EIA. That said, staying active is possible if you take precautions.

Make sure to work with your allergist to fully understand what triggers anaphylaxis for you and develop an individualized action plan in the event of anaphylaxis. Dr. Randhawa also recommends the following steps to exercise safely:

Avoid trigger foods for 4 to 6 hours before exercise.
Exercise with a partner who knows how to use epinephrine.
Always carry two epinephrine auto-injectors or nasal sprays.
Avoid exercising in extreme heat or when you’re sick.
Wear a medical ID bracelet that states you have EIA.

“It’s important for patients to know there are therapeutic options beyond avoidance,” says Lighvani. “But they need to be educated about how to appropriately treat reactions.”

Anaphylaxis can occur during or shortly after physical activity. This is known as exercise-induced anaphylaxis (EIA). The most common type of EIA is food-dependent, exercise-induced anaphylaxis (FDEIA), which occurs when a trigger food is eaten before exercising.
If you think you’re experiencing EIA, stop exercising immediately, administer epinephrine, and seek emergency medical care.
You can work with an allergist to formally diagnose EIA and come up with an action plan to keep yourself safe. That plan may include exercising with a partner who knows how to administer epinephrine, avoiding certain types of exercise, and limiting exercise in extreme temperatures.

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