1.  Food-dependent exercise-induced anaphylaxis (FDEIA) is a special subtype of food allergy occurring only when the two triggering factors(culprit food and exercise) are present simultaneously.  However, this reaction is not always manifested in the challenge test. So it may be considered that there are some other provoking factors and NSAID is one of them. Abstract Case Conclusions  Although the exercise challenge test can be used to diagnose FDEIA precisely, it has some difficulties to get positive results when applied clinically because it’s reproducibility is low.  Therefore, we should always consider other combined provoking factors. In this case, we can confirm FDEIA by food-exercise challenge test with NSAID ingestion. g Seung-Hyun Lee, Jae-Hyun Lee, Jung-Won Park, *Chein-Soo Hong A case of wheat-dependent exercise-induced anaphylaxis provoked by NSAIDs Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea Figure 1. Serial challenge test design for FDEIA Exercise challenge test Exercise only Figure 2. Results of Specific IgE by CAP A 22-year-old male visited clinic due to his repetitive history of dyspnea, urticaria, skin rash and loss of consciousness. The first episode was occurred after he had eaten fried chicken and then walked for 1.5 km. Soon after he experienced dyspnea, urticaria, whole body skin rash, both hands swelling and loss of consciousness. At that time he had taken a medicine, Mypol® (Acetaminophen, Codeine phosphate, Ibuprofen) due to back sprain for 3 months. He was sent to the Capital Armed Forces Combined Hospital where he underwent an exercise challenge test with chicken. The result was negative.  A 22-year-old male visited clinic due to his repetitive history of dyspnea, urticaria, skin rash and loss of consciousness. The first episode was occurred after he had eaten fried chicken and then walked for 1.5 km. Soon after he experienced dyspnea, urticaria, whole body skin rash, both hands swelling and loss of consciousness. At that time he had taken a medicine, Mypol® (Acetaminophen, Codeine phosphate, Ibuprofen) due to back sprain for 3 months. He was sent to the Capital Armed Forces Combined Hospital where he underwent an exercise challenge test with chicken. The result was negative.  Since then, however, he experienced the similar systemic allergic symptoms four times during following 7 months. So he was evaluated with impression of FDEIA. In skin prick test, wheat grain and wheat flour of food allergens were negative and Sagebrush, D. pteronyssinus, D. farinae of inhalant allergens were strongly positive (4+). In the laboratory findings, specific IgE by CAP was 3.76 kU/L and 16.6kU/L against both wheat and omega 5-gliandin and total IgE was 1247 kU/L. Other CAP results were 81.0 kU/L against Phadiatop, 0.10 kU/L against Buckwheat.  Based on his past medical history and lab findings, we planned serial challenge tests under three different conditions – exercise only, exercise with wheat, and exercise with wheat and NSAID. The first exercise challenge on the treadmill was practiced for 30 minutes and the result was negative. The second one was practiced 30 minutes after he ate a half piece of pizza dough (100 gm) and he ran on treadmill for 30 minutes. He reported mild dizziness, a few urticarial wheals and rashes on left upper quadrant area in abdomen. The last one was practiced thirty minutes after he took pizza dough and ibuprofen 400mg. The anaphylactic shock was developed 18 minutes after exercise on treadmill. He was fully recovered with emergency treatments with shots of epinephrine and antihistamine. Exercise with wheat Exercise with NSAIDs Exercise with Wheat + NSAIDs Negative Anaphylatic Shock CAPIgE (kU/L) Total IgE 1247 Wheat 3.76 Buckwheat 0.10 Omega-5 Gliadin 16.6 Phadiatop 81.0 Ragweed 0.43 Sagebrush 0.30 Japanese Hop 0.07 D. Pteronyssinus 26.6 D. farinae 75.5