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Exercise Induced Anaphylaxis:  What To Know?

by Dr. Inderpal Randhawa, M.D.

Screenshot_2015-10-02-13-19-01 (2)Anaphylaxis from all causes impacts over 3 million Americans annually.  The most common cause of anaphylaxis involves the most common food triggers- milk, egg, wheat, soy, tree nuts, peanut, fish and shellfish.  Other triggers include medications, contrast dye, non-steroid anti-inflammatory drugs (NSAIDs), and other causes.  A very rare but interesting form of anaphylaxis is termed exercise induced anaphylaxis.

Exercise induced anaphylaxis has been described for decades.  It involves a patient eating foods like wheat or celery and typically one hour after ingestion with moderate exercise resulting in anaphylaxis symptoms.  The symptoms can be as mild as fatigue, red skin, lightheadedness, and throat tightening.  Symptoms can progress to life threatening anaphylaxis.  The causal relationship of the reaction is unclear.  The reaction is likely related to histamine release from mast cells and basophils primed by the food allergen exposure.

When should a parent be concerned about exercise induced anaphylaxis?  If a child, especially a teenager, notices a reduction in exercise tolerance after a new food exposure, it is worth a discussion with your primary care doctor.  It may be appropriate to perform food allergy testing and an exercise cardiopulmonary challenge to make the diagnosis.

An important note for OIT patients:  the reason most clinicians recommend a rest period after food dosing is due to the risk of a similar reaction described above.




The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment. We expressly disclaim responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered as a result of your reliance on the information contained in this site.

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Our OIT Superhero

by Pujal Patel

Aanya Photo 2Aanya was born with a milk allergy. Barely a day old in the NICU, a nurse fed her cow based formula and she started projectile vomiting.  She was JUST A NEWBORN! It took us a few days to figure out that the issue was milk, not overeating! We came home with a newborn and advice to breast feed only, no milk based formula.

At 9 months old, our pediatrician asked us to ‘try’ some yogurt.  One lick resulted in full body hives, severe GI upset and fussiness for days. After being referred to an allergist, she tested positive for milk and nut allergies (we were already avoiding nuts due to her older sister who had multiple nut anaphylaxis).  We were sent home with epi pens and advice to avoid her allergens (which were everywhere!!!).

Aanya was two years old when, at the touch of chickpea chutney, she went into anaphylaxis. She had major GI distress, hives all over her tiny body, facial swelling and was struggling to breathe. I will never forget her frantically clawing at her chest with her tiny little hands. An EpiPen saved her life!

That night I knew we couldn’t keep our kids alive just by avoiding their allergens; danger lurked around every corner no matter how hard we tried. That was the darkest night but fortunately a light came on in the form of Dr. Inderpal Randhawa. I was full of hope for the first time when I walked out of our consultation appointment. After running comprehensive tests, Dr. Randhawa put Aanya on SLIT (Sublingual Immunotherapy) which greatly helped as she also had a history of asthma attacks every 3-4 weeks. Her asthma usually ended up in nebulization, steroids and lots of urgent care and doctor visits.

We then embarked on our OIT journey with milk, followed by almonds, pine nuts, pistachio, cashew, macadamia, and pecans. We will soon be working on the remaining tree nuts, peanuts and chickpeas!!

We cannot thank Dr. Randhawa enough! We were barely surviving and now we have this new life, full of freedom, just like childhood should be!! He is our SUPERHERO!!!

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It’s National Peanut Day:  Time to Understand the Anatomy of Peanuts

Why is it important in general to understand the inner “workings” of various nuts?

All nuts are composed of many components or subparts.  The most common parts are fats, carbohydrates, vitamins, minerals, water and protein.  When it comes to peanut food allergy, the protein is the most important part.

Why is knowing the subparts very important in OIT?

It is very important to know the subparts of peanuts in OIT to better understand dosing.  When a patient is able to eat one peanut, what does that really mean?  It means how much actual “food allergy molecule protein” is that child now eating.  This is particularly important when understanding the concept of safety.

For example, if a patient can tolerate 8 peanuts daily after being treated with OIT, can the patient safely eat more than 8 peanuts at any time?  The answer lies in that patient’s immune system response to OIT.  If the patient has demonstrated improved clinical markers of sensitization and clinical evidence of tolerating high doses of peanut, the question of safety is answered more scientifically.

What are the different types of peanuts?

Peanut Comparison

There are several types of “typical” peanuts in the United States.  Please keep in mind species of peanuts in China, India and Africa have different protein structures and weights than US based peanut products.  The most common US peanut is the runner peanut.  It is available at any grocery store.  Since each type has different weights, it is important to discuss the properties of these peanuts with your allergist when deciding how much of which peanut to consume during maintenance.

How much protein is in one peanut?

On average, 10 grams of peanuts are used to pass a food challenge in any standard allergy practice office.  This is deemed a “pass” for non-allergic patients.  10 grams of runner peanuts equals 18-20 peanuts daily.  However, this is the total weight of the peanuts.  How much actual protein is in the 18-20 peanuts?  It depends on whether the peanuts are heavily roasted or not roasted at all.  If it is unroasted, the protein count ranges from 5-6 grams.  If it is heavily roasted, it can range from 4-6 grams.

Of greater interest is what amount of protein actually contains the high anaphylaxis risk epitope sequences of Ara h1, Ara h2 and Ara h3.  Early experiments to purify this protein resulted in some approximations of the dosing.  However, an exact amount of how much of these epitopes is unclear.  The likely percentage ranges from 5-15% of the total protein is comprised of the high risk sequences.

Why do the number of maintenance peanuts matter?

Based on the last question’s response, everyone’s immune system responds to peanut protein differently.  Some may respond very quickly to OIT and their maintenance dose can be 20 grams every month in order to successfully maintain a “sensitized” immune system.  However, others may need to eat 10 grams every day to maintain the same sensitization.

Again, the anatomy of the peanut is important.  It contains complex subparts of which the protein is most important.  Specific epitopes of the protein are of even greater importance for food allergy dosing and safety.  One goal of research at The Translational Pulmonary & Immunology Research Center (TPIRC) is to better study and define the anatomy of peanut protein responsiveness in order to fine tune each patient’s maintenance dose to ensure maximal safety and simultaneously ensure maximal long term benefit.

Inderpal Randhawa, MD

Chief Medical Officer, TPIRC



U.S. Department of Agriculture, Agricultural Research Service. 2013. USDA National Nutrient Database for Standard Reference, Release 25.

10.4049/​jimmunol.169.2.882.  The Journal of Immunology July 15, 2002.  vol. 169  no. 2  882-887


The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.

We expressly disclaim responsibility, and shall have no liability, for any damages, loss, injury, or liability whatsoever suffered as a result of your reliance on the information contained in this site.

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by Leah Roffman

We have all seen the stereotypical portrayal of the allergy and asthma nerd. While I am proud to call myself a nerd, I take issue with the often weak, unpopular and uncoordinated caricature of the allergic and asthmatic child. I have carried the diagnosis of Food Allergies, severe Asthma, and Inflammatory Disorders my entire life. Contrary to the usual portrayal, I believe that the trials and tribulations of navigating a poisonous world has made me stronger.

Many of the less empathetic (let’s call these people “insensitives”) insist that severe food allergies are the same as the Pollen sniffles they get every spring. Much of the world remains misinformed about the dangers of anaphylactic allergies. As a result of this ignorance, insensitive people refuse to limit their consumption of airborne allergens in public places. Consequently, while advocacy and food allergy awareness remain near and dear to my heart, I realize that it is equally important to move swiftly toward the eradication or at least suppression of life threatening allergies.

Many people in my life would actually advise me …so if you’re allergic to it, just don’t eat it and you should be fine – those people completely ignoring the literature proving that many food allergies are airborne.  Once the allergens reached my body, whether through my mouth, my skin, or my nose, they caused a cascade of systemic reactions. The inflammation caused by my intense reaction to these microscopic molecules of destruction caused my body to be rapidly overwhelmed by itching, swelling, sneezing, coughing and worse.

After many emergency room visits, steroids, prolonged school absences and accompanying social consequences, my medication list kept growing.  One night, in middle school, I went to see the Harry Potter Midnight Premiere with a friend at which time something in the theater caused a severe allergic reaction.  The emergency room took a CT scan of my lungs which showed some nodular changes.  At that time my family decided that I could never recover in Michigan with the allergens and severe weather changes.  We picked up and moved to California in time for my first year of high school.

Unfortunately, things got so bad with my asthma that my immune system was beat. I was hospitalized with H1N1 my first week of high school. I was on IV Steroids and oxygen for a week and continued steroids for the better part of my first semester of school.  The steroid weight gain caused problems with my confidence as I had been a physically fit dancer up to that point.

I was allergic to Eggs, Nuts (peanuts and tree nuts and every cousin of legumes such as beans) and Fish (finned fish and shellfish). I was airborne. I couldn’t be within 10 feet of Nuts or Fish or I was at risk of anaphylaxis. The enemy was literally everywhere.  

By way of example:

– I went to Epcot with my family one year when they had Walnut trees on the grounds.  I broke out into hives 5 minutes inside the park.

– When I went to the movies we used to bring a towel for me to sit on so my skin never touched the seat.

– I’ve never been to a baseball game.

– I sat at a special table at lunch accompanied by a recess monitor to make sure I was safe-every single day of elementary school.  

– I was not allowed to play outside at recess during most of the winter due to my asthma.

– My first boyfriend had to give me a rundown of every food and beverage he consumed for the day if he intended to kiss me.

– I could only go to a few restaurants after the menu was checked out and with the clear understanding that they would cook in areas that were not cross contaminated.

– I could not get my hair washed or styled in a salon since we didn’t know if there were nut oils in the products. (Or manicures)

– My teachers had to physically carry a hip pack with EpiPen, liquid Benadryl, and inhaler– from room to room since I couldn’t have it too far away.

– My parents donated massive quantities of wipes to the school so that after lunch all hands could be wiped under supervision.

– My only camp experience was at an air conditioned dance camp. They went out of their way to keep allergens away from the camp. Nevertheless, my parents brought every single piece of food that I ate for the week

– I never got to ride the bus to field trips with the rest of the children. It was too much risk that someone would have an allergen aboard and there was no adult available to medicate me.

– My favorite game in high school was “Never Have I Ever” because of all the things I couldn’t eat or do.

Eventually, my body got so hyper-allergic to everything that I actually developed an allergy to cockroaches, which are often found in public high schools in California. I would develop a sandpaper rash as soon as I entered my high school campus.  I started an online program for my last two years of high school because I couldn’t stay in a public school with cockroaches and peanut dust.

The treatment was often isolating. I had recurrent pancreatitis from so much steroid use.  I was in such a dark place at that time. My illnesses were a source of stress at school, in dance class, and in my social life. I was depressed, I felt alone.

When I was 16, I was seeing a neurologist for severe migraines. A mother of another patient referred my mother to a specialist by the name of  Dr. Randhawa. We didn’t know it then, but that little business card was the start of the rest of my life.

When my parents took me to Dr. Randhawa, I was angry, depressed, and very skeptical. Every so called “specialist” I’d seen in California had failed me.  I was hostile and not very nice to him the first visit.

In spite of my negativity, the doc immediately started trying out different treatments and ordering tests. As we started to focus my issues, the doc started me on a new drug that he thought would help with the pain and help me get back out into the world.  I started sublingual immunotherapy (SLIT) for the environmental allergens.  As I started to improve, we realized my asthma was still causing more problems.  Dr. Randhawa suggested an injected drug that would help the allergic asthma…adding that it might also be helpful in reducing many of my allergies. I thought he was crazy.  Nevertheless, I agreed to the injections and improved dramatically.  With that success, Dr. Randhawa started to educate my family on the options of Oral Immunotherapy.  

Initially I refused, explaining that he previously described my food allergies as “off the charts” and “some of the highest test results he had seen”, and now he wanted to start feeding me the things I was allergic to? I wasn’t going to let that happen, and neither was my mom. He patiently explained in more detail his procedure (for more information on OIT treatment click here). We decided to try it.  I am so happy about that decision.

Fast forward 4 years:

– I’m a Sophomore in college (I got a 4.0 last semester).   

– I’m on the speech and debate team.   

– I feel free to go where I need to and do what I need to without the constant fear of death by lunch.

– I’m eating as many eggs daily as I please, a peanut butter and jelly sandwich every night, and every type of nut out there is A-OK.

– I can go to restaurants and Disneyland and Comic Con all by myself without worrying that something terrible will happen.

My world has completely changed from the young, fear-filled, little girl I was my entire life. I’m not ruled by my illness. The world is out there and I am ready to embrace it.


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