K., a 16 yr old boy, had never eaten a vegetable until his girlfriend's father decided that to continue her friendship he'd need a healthier diet. His first bite, of tomato, provoked immediate cough, gagging, difficulty breathing, “tight throat,” chest pain and vomiting. Two re-challenges provoked the same symptoms and also explosive diarrhea, leading to an ER visit and tentative diagnosis of food-allergic anaphylaxis. PFT showed laryngobronchial irritant changes (clipped F-V loops). Fiberoptic rhinopharyngoscopy showed changes characteristic of “graviational GERD.” K. returned 3 months later when, as one of the faster swimmers on his school team, he was being asked to swim fast enough to win but not too fast, as all out effort often provoked coughing, choking, gagging and sometimes vomiting before he could reach the end of the pool. He reported having had heartburn, controlled by diet plus either 8” elevation of the head of his bed or a proton pump inhibitor (PPI) before supper. PFT now showed reduced irritant changes. Inhaled steroid did not reduce swimming-associated symptoms but PPI before breakfast on swimming days prevented them. K found esomeprazole more effective and less irritating than three other PPI. Tomato skin tests were negative. Re-challenge with tomato reproduced K's original symptoms. We asked K. to repeat tomato challenge after esomeprazole.

GER masqueraded first as food allergic anaphylaxis and then as exercise-induced asthma in a 16 year old boy.