Flushing, Paresthesias, and Difficulty Swallowing After a Run
John D. Cantwell, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 1 - JANUARY 2021
The patient's ECG showed left ventricular hypertrophy (figure 2), which was probably normal for a distance runner. An echocardiogram done 2 years previously, when his ECG had shown similar changes, had revealed normal left ventricular chamber size, thickness, and function, with an ejection fraction of 65%. Mild mitral valve prolapse and a trace of mitral regurgitation had also been observed.
Because the patient had been in New England when he had had his episode, the key follow-up exam question was whether he had eaten any shellfish prior to his run that day. Shellfish, along with certain other foods such as celery, peaches, grapes, wheat, cabbages, chicken, apples, and hazelnuts, have been implicated as possible triggers for an exercise-induced allergic reaction, the most likely cause of this patient's symptoms (1) Associated hyperventilation might also have contributed to his symptoms.
The patient reported that he had eaten lobster a few hours before his episode, adding that he usually avoided it because it had once made him ill as a child. He had also eaten peaches, grapes, and celery earlier that day.
The first reported case of a food-dependent, exercise-induced, severe allergic reaction occurred in a 31-year-old man who had ingested shellfish 5 to 24 hours before running (2). His symptoms included urticaria, facial flushing, and laryngoedema. In such food-related instances, exercise may facilitate absorption of the particular antigen or perhaps lower the threshold for mediator release from immunoglobulin-G-sensitized mast cells. In addition to certain foods, substances that can trigger reactions include alcohol, antibiotics, aspirin, other anti-inflammatory agents, and over-the-counter cold remedies.
Treatment can involve up to 0.3 mL of epinephrine (1:1,000) injected subcutaneously, repeated in 20 to 30 minutes if necessary, along with oxygen, intravenous diphenhydramine hydrochloride, and, if the patient is hypotensive, normal saline intravenously.
Our patient had a mild, largely self-limited reaction characterized by skin flushing and probable laryngoedema. He was advised to avoid the likely offending foods, especially on the days of his distance runs. We did not choose to do prick-skin testing or other tests for specific immunoglobulin E antibodies to foods, but will consider these if he has further problems.
Dr Cantwell practices cardiology at Cardiology of Georgia, PC, and is a clinical professor of medicine at Morehouse School of Medicine in Atlanta. He is also a member of the editorial board of The Physician and Sportsmedicine. Address correspondence to John D. Cantwell, MD, 755 Mt Vernon Hwy, Suite 530, Atlanta, GA 30328.
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