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Research Letter
Cow's milk dependent exercise-induced urticaria after oral tolerance induction in an adolescent
M. Couto, Â. Gaspar, C. Santa-Marta, M. Morais-Almeida
Corresponding author
mmoraisalmeida@netcabo.pt

Corresponding author.
Immunoallergy Department, CUF-Descobertas Hospital, Lisbon, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Exercise-induced urticaria &#40;EIU&#41; is a clinical syndrome in which urticaria occurs in association with exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> EIU may occur independently of food or may require the ingestion of a food allergen prior to exercise&#44; in a process of food dependent exercise-induced urticaria &#40;FDEIU&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">During oral tolerance induction &#40;OTI&#41; to cow&#39;s milk &#40;CM&#41; in allergic children&#44; many factors have been pointed out as being responsible for a higher risk of allergic reactions with CM doses previously tolerated&#44; being exercise the most common one&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However&#44; prospective data concerning this subject after ending OTI are still lacking&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report the case of a 16-year-old male&#44; referred to our Immunoallergy department in 2002&#44; at the age of eight years&#44; reporting an IgE-mediated cow&#39;s milk allergy &#40;CMA&#41; diagnosed at four months of age following an episode of anaphylaxis&#46; Since then he began strict allergen avoidance&#44; although he has experienced four anaphylactic reactions by accidental ingestion of hidden CM&#46; He also reported intermittent asthma and persistent rhinitis plus family history of atopy&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Skin prick tests &#40;SPT&#41; were positive to grass pollens&#44; whole CM&#44; casein&#44; &#945;-lactoalbumin and &#946;-lactoglobulin &#40;Laboratorios Leti&#44; Madrid&#44; Spain&#41;&#46; Total IgE was 262kU&#47;L and sIgE to whole CM 47kU&#47;L&#44; casein 51 kU&#47;L&#44; &#945;-lactoalbumin 9 kU&#47;L and &#946;-lactoglobulin 2 kU&#47;L&#44; and increased throughout the years&#44; reaching 350 kU&#47;L to whole CM in 2005 &#40;Phadia&#44; Uppsala&#44; Sweden&#41;&#46; Oral food challenges were regularly performed to evaluate tolerance&#44; and consecutively caused anaphylaxis&#59; the last one&#44; at 11 year-old&#44; was positive with 10<span class="elsevierStyleHsp" style=""></span>mL&#46; Because of this persistency&#44; we decided to start OTI at that age&#46; He was successfully submitted to an eight-week protocol&#44; reaching a daily dose of 200<span class="elsevierStyleHsp" style=""></span>mL&#44; which allowed a free diet&#46; He was advised to maintain CM ingestion daily&#44; after a meal&#44; and to avoid vigorous exercise in the two subsequent hours&#46; Although he is an athlete&#44; he strictly respected these indications&#46; A few months after OTI&#44; however&#44; he presents reproducible episodes of EIU when the exercise was unplanned and CM ingestion had occurred within the two previous hours&#46; Episodes resolved with anti-histamine and oral corticosteroid&#46; He has no other episodes of urticaria or other symptoms with CM&#46; sIgE to whole CM in 2010 was 2kU&#47;L&#44; to casein 2&#46;5kU&#47;L and the remaining were negative&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">CM OTI is an increasingly attractive strategy&#44; and success has been achieved with several different protocols&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Long term follow-up is not available since this is a recent procedure&#44; but data point to be generally well-tolerated and safe&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In EIU food can act as a co-trigger&#59; wheat is most commonly reported&#44; but other foods can be implicated&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> It is hypothesised that in these patients&#44; food-sensitised immune cells are relatively innocuous until they are redistributed into the systemic circulation from gut-associated deposits during exertion&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> which is probably what occurs with our patient&#46; Similarly&#44; Caminiti et al&#46; described a case of food dependent exercise-induced anaphylaxis in a child successfully desensitised to CM&#44; however he was submitted to a longer OTI protocol of 180 days<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; although more severe&#44; his episodes were easier to control by his parents&#44; because exercise was planned&#46; We could speculate if this side-effect &#40;anaphylaxis&#41; more severe than just urticaria could be due to different protocols used&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is the first time&#44; to our knowledge&#44; that FDEIU is described in an adolescent as a side-effect of successful CM OTI&#44; in which episodes are difficult to control because of his age and the unplanned way that exercise occurs&#46; This case report strengthens the fact that the persistency of this CM tolerance is not yet known&#44; and that external factors may be responsible for its breakdown&#44; despite specific IgE decrease&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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Article information
ISSN: 03010546
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