Anaphylaxis Induced by Exercise or Cold Stimulation with Hyperleukotrieneuria During a Challenge Testing Not Containing Food Ingestion

Abstract Background: Exercise-induced anaphylaxis (EIA) is rare and a potentially life-threatening disorder that can develop independently without food ingestion. Cold drinks can also trigger symptoms in some patients with cold-induced anaphylaxis. We present the case of a patient with exercise and cold-induced anaphylaxis that was diagnosed based on hyperleukotrieneuria in exercise loading and cold-drink challenge testing.Case presentation: A 12-year-old girl presented with acute flushing, cyanosis, swollen eyelids, and dyspnea after an endurance run in winter or swimming in a cold-water pool. She also developed dyspnea after having a cold drink. She had no history of food allergies or atopy. No association was noted between anaphylaxis and food intake in her history. On the 1st day, she ingested 200 mL cold water at a temperature of 5°C in 30 s, which did not trigger any symptomatic responses, but urinary LTE4 level increased (pre-challenge test 295 pg/mg.cr, post-challenge test 400 pg/mg.cr). On the 2nd day, she underwent the exercise loading test according to the Bruce protocol by increasing the power of exercise every 2 min using an ergometer. She had been fasting for >15 h and did not have breakfast. Just after the exercise loading test, the plasma adrenaline and noradrenaline increased. At 15min. after the exercise loading test, the plasma adrenaline and histamine (pre-challenge test 0.7 ng/mL, 15min.post-challenge test 81 ng/mL) rised sharply with anaphylaxis symptom accompaneid by increasing of urinary LTE4 (pre-challenge test 579 pg/mg.cr, post-challenge test 846 pg/mg.cr). After she was discharged, she was restricted from strenuous exercise especially in cold environments and prescribed an adrenaline autoinjector.Conclusion: To our knowledge, cold stimulation becomes a co-effector for EIA. Measurements of urinary LTE4 levels during challenge testing are useful to diagnose anaphylaxis induced by exercise or cold stimulation.