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Month: January 2018

Allergies to the Cold Weather

This is a very relevant subject now as we have had very cold temperatures so far over this last month in the Washington, DC, Northern, VA, and Maryland metropolitan area.  And yes, you read it correctly.  Individuals can be “allergic” to the cold.  There is a condition known as “cold-induced urticarial” in which exposure to the cold will cause hives (i.e., urticaria).  The annoying hives can be triggered by cold weather or cold water.  Being exposed to the cold weather, swimming in cold water, drinking a cold beverage, and/or being in an air conditioned room may all cause certain individuals to develop hives and other symptoms.  In addition to the hives, these other symptoms usually present as swelling (i.e., angioedema)itching (i.e., pruritus), redness of the skin or other rashes, dizziness, fatigue, wheezing, headaches, anxiety, and/or shortness of breath.

It is not uncommon to experience “cold” allergies and in some families, there is a genetic linkage.  Many people are perplexed with the notion that the cold environment can cause such symptoms.  Keep in mind that it is not unusual for anyone to experience minor symptoms when exposed to the cold weather.  These “normal” responses generally consist of a little red flushing of the exposed part of the body (usually the face).  One may also experience a minor burning sensation, especially upon re-warming of the involved skin.  Obviously, individuals that are exposed to very cold temperatures or cold temperatures over a prolonged period of time run the risk of frostbite which can be very serious, as it may result in gangrene and thus loss of limbs and other body parts.

Individuals with Raynaud’s phenomenon or Raynaud’s disease also have cold intolerance.  People with these conditions have cold fingers or toes, skin color changes, and/or numbness/prickly feeling upon re-warming of the skin when they are exposed to the cold.  Although the exact cause is not completely understood, the blood vessels in individuals with Raynaud’s overact to cold temperatures and/or stress.  Often people with Raynaud’s phenomenon will have an accompanying autoimmune disorder such as systemic lupus erythematosus, scleroderma, Sjögren’s syndrome, vasculitis, or rheumatoid arthritis.  Others still have increased symptoms if they smoke, develop carpal tunnel syndrome, acquire a disease of the arteries, partake in repetitive actions such as playing the piano, texting, typing, etc., injure their hands or feet, and/or are exposed to certain medications (e.g., ADHD medications, certain over the counter “cold” medications, migraine medications, certain chemotherapy medications, beta blockers).

Regardless of the condition, the cold can play havoc with one’s body.  Luckily, we do not live in the far north of the U.S. where cold is more of an issue for longer periods of time.  However, since we live in a more temperate climate, allergies to pollens (i.e., allergic rhinitis/hay fever) in the Spring and Fall tend to be worse in the Washington, DC, Northern Virginia, and Maryland metropolitan area.

If you suffer from cold-induced symptoms of any kind, the board certified allergists at Black & Kletz Allergy have the expertise in order to diagnose and treat this condition.  We treat both adult and pediatric patients and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have on-site parking at each location and both the Washington, DC and McLean, VA offices are Metro accessible.  Please either call us for an appointment or you may alternatively click Request an Appointment and we will respond within 24 hours by the next business day.  The allergy doctors at Black & Kletz Allergy have been treating allergy and asthma patients in the Washington, DC metro area for more than 50 years and we strive to provide state of the art allergy care to its residents and visitors.

Food-Dependent Exercise Induced Anaphylaxis

Food-Dependent Exercise Induced AnaphylaxisExercise-induced anaphylaxis (EIA) is defined as the onset of allergic symptoms during, or immediately after, exercise.  The manifestations may include hives (i.e., urticaria)swelling of the soft tissues (i.e., angioedema)generalized itching (i.e., pruritus), wheezing, shortness of breath, nausea, dizziness, fainting, and/or a drop in blood pressure.  In some individuals, these reactions occur only if exercise is undertaken after eating certain specific foods!  When the food intake and the exercise are independent of each other, there are no symptoms.  This condition is termed “food-dependent exercise Induced anaphylaxis” (i.e., FDEIA).

Symptoms of FDEIA may begin at any stage of exercise and occasionally occur just after exercise.  The offending food is usually ingested within 4 hours preceding exercise, or rarely just after exercise.  The frequency with which symptoms occur varies among patients with FDEIA and can be very unpredictable, even for a given patient.  Early signs and symptoms may include fatigue, diffuse warmth, flushing, and/or generalized itching.  These symptoms usually subside after some time if the person stops exercising.  If the exercise is continued however, it can lead to swelling of the throat, breathing difficulty, drop in blood pressure, and vascular collapse which can potentially be fatal.

Though a wide variety of foods are known to play a role, the most common foods which have been observed to cause this condition are grains (especially wheat) and nuts in Western populations and shellfish in Asians.  Most patients develop symptoms only after eating a specific food, although a few have attacks if any food (usually solids rather than liquids) has been ingested.  Patients have been described where symptoms occurred only if 2 foods were eaten together before exercise.  The processing of the food(s) may also be critical in some cases, such as a patient who developed FDEIA with tofu but could tolerate soy milk.

The exact mechanism of how food plus exercise triggers life-threatening reactions is not clearly known.  A leading theory suggests that physical exertion enhances the absorption of the food from the gut. Ingestion of alcohol can also facilitate this condition, probably by the same mechanism.  Another hypothesis suggests that exercise stimulates the mast cells (which are previously sensitized to specific food proteins) to release chemical mediators responsible for the reaction.  In some instances, taking medications such as aspirin or nonsteroidal anti-inflammatory drugs [(e.g., Motrin, Advil (ibuprofen), Aleve (i.e., naproxen)] can also contribute to the reaction, supporting the hypothesis of mast cell activation.

As mentioned above, wheat is the most commonly reported allergen in FDEIA overall.  Gliadin, a protein component of gluten, is an important allergen in this disorder, as well as in wheat allergy causing anaphylaxis independent of exercise.


The following criteria are needed to establish the diagnosis of FDEIA:

  1. Signs and symptoms consistent with anaphylaxis that occurred during (or within 4 hours of) exercise but only when exercise was preceded by food ingestion.
  2. No other diagnosis that explains the clinical presentation.

If a specific food is implicated, there should be:

  1. Evidence of a specific antibody to the implicated food, either by skin tests or by blood tests and
  2. No symptoms on ingestion of that food in the absence of exertion and no symptoms if exercise occurs without ingestion of that food, although there may be rare exceptions (i.e., patients may report isolated incidences when symptoms occurred at rest in the presence of other exacerbating factors, such as illness).

A serum tryptase level should be measured in all patients and should be normal in individuals with FDEIA when the patients are in their usual state of health.  Elevated levels at baseline should prompt an evaluation for a mast cell disorder.

Skin testing or blood testing for environmental allergens is sometimes useful if the patient is more susceptible to attacks during certain pollen seasons or in a patient with concomitant allergic respiratory disease such as asthma.

A positive food plus exercise challenge confirms the diagnosis, but a negative challenge does not reliably exclude the diagnosis because symptoms can be difficult to induce in a laboratory setting and the procedure is not standardized.


Avoidance of ingesting the suspected food before exercising is critical.  Identification of aggravating factors such as alcohol, aspirin, and/or nonsteroidal anti-inflammatory drugs and their avoidance is also important.

  1. Always carry an epinephrine self-injectable device (e.g., EpiPen, Auvi-Q, Adrenaclick) and mobile phone in all exercise settings.  If the epinephrine is ever used, always go immediately to the closest emergency room.
  2. Stop exertion immediately if any symptoms occur (never “push through”).
  3. Avoid the causative food for at least 4-6 hours before exercise.
  4. Always exercise with other informed individuals.

In some individuals with this condition, pre-treatment with certain medications such as first generation antihistamines and/or cromolyn may provide some preventive benefit.  It should be noted that this is not a substitute for avoidance of eating the allergic food and then exercising.

The board certified allergists at Black & Kletz Allergy will promptly respond to any questions regarding FDEIA and other allergic or immunologic disorders.  We have been treating this condition for many years and have offices in Washington, DC, McLean, VA (Tysons Corner, VA), and Manassas, VA.  We have been serving the Washington, DC, Northern Virginia, and Maryland metropolitan area for over 50 years and treat both adult and pediatric patients.  All 3 offices at Black & Kletz Allergy offer on-site parking and the Washington, DC and McLean, VA offices are Metroaccessible.  There is a free shuttle that runs between our McLean, VA office and the Spring Hill metro station on the silver line.  If you are concerned that you may have FDEIA or any other allergy, asthma, sinus, skin, or immunology problem(s), please call us to schedule an appointment.  You may also click Request an Appointment and we will reply within 24 hours by the next business day.  At Black & Kletz Allergy, we strive to improve the quality of life in allergic individuals in a professional and caring setting.