Delayed food-dependent, exercise-induced anaphylaxis.

Food-dependent, exercise-induced anaphylaxis (FDEIA) is a clinically distinct form of anaphylaxis in which symptoms occur only when the patient exercises within a few hours of eating the food. Its precise mechanism remains unclear and has been reported to have a wide spectrum of presentations. The objective of this report is to show that the onset of FDEIA can be delayed for several hours and to emphasize the critical need for having self-injectable epinephrine available at all times. Our patient had several episodes of FDEIA to wheat shortly after exercise since the age of 11 years. At 16 years of age, 5 hours after exercise that followed eating a wheat-containing meal, the patient developed severe anaphylaxis with loss of consciousness. Skin-prick test was positive (4+) to wheat but negative to 41 other foods. Serum tryptase level 2 hours after onset of anaphylaxis was elevated. Other laboratory findings were within normal ranges. This case indicates that FDEIA can have a delayed onset for several hours. Because such delayed onset is unpredictable and can be life-threatening, it might be prudent for such patients to avoid the offending food totally or to avoid exercising for at least 6 hours after eating the food and to keep self-injectable epinephrine easily available at all times.

Rhinorrhea not responding to nasal corticosteroids.

A woman with multiple illnesses including allergic rhinitis presented for a follow-up visit at our clinic with constant rhinorrhea for 2 weeks despite regular use of nasal corticosteroids. Two weeks earlier, after alcohol drinking and doubling some of her medications for missed doses, she fell on her face. The Emergency Department records documented headache, bradycardia, hypotension, dehydration, and right infraorbital swelling. She was admitted for hydration and observation, and was discharged after two days without radiologic evaluation of the head. At our clinic, physical examination revealed pale turbinates bilaterally and clear watery discharge from the right nostril. Cerebrospinal fluid (CSF) rhinorrhea was suspected, but glucose testing was not available at our clinic. The patient was immediately admitted into the hospital. A beta-2-transferrin test confirmed CSF from the right nostril. High resolution sinus CT revealed fluid in the right sphenoid sinus, a large cyst in the left maxillary sinus, a cribriform plate dehiscence on the right side, and fluid collection adjacent to the middle turbinate. A lumbar drain was placed to release the pressure and antibiotic prophylaxis was started. Nasal endoscopy revealed CSF leak from the cribriform plate with bone dehiscence and a dural tear. A graft from nasal septal cartilage and temporalis fascia was applied using Tisseal fibrin glue. The persistent rhinorrhea resolved and on follow-up visits, the patient remained asymptomatic. Thinking of CSF rhinorrhea in the differential diagnosis of rhinitis would lead to early diagnosis and prevention of serious medical complications and potential legal liabilities.