Adverse
and allergic reactions to alcoholAlcohol is a natural product
Alcohol (ethanol) is a normal by-product of human and animal
cell chemistry/metabolism. Cell processes result in normal physiological
levels of 0.01 to 0.03 mg of alcohol/100 ml of blood. By contrast,
a blood alcohol limit for driving of 0.05 per cent is equivalent
to 50 mg of alcohol/100 ml of blood.
Alcohol is broken down in the liver
Alcohol (ethanol) is broken down by liver enzymes within minutes.
Conversion of ethanol to acetaldehyde requires the enzyme alcohol
dehydrogenase. Acetaldehyde is then transformed to acetic
acid ("vinegar") by the enzyme aldehyde dehydrogenase.
If individuals can't break down alcohol easily, problems may occur
if alcohol is consumed.
Flushing is not an allergic reaction
Some patients will experience intense facial flushing after
having even small amounts of alcohol. These symptoms are most
common in those with an oriental / Asian background. Other side-effects
include fluttering of the heart (palpitations, tachycardia), sensation
of heat, headache, abdominal discomfort or a drop in blood pressure
(hypotension) are related to high blood acetaldehyde levels. Patients
with these problems appear to be partially deficient in aldehyde
dehydrogenase, resulting in high levels of accumulated acetaldehyde.
Other conditions may also trigger flushing
Not all flushing is due to alcohol. Similar flushing reactions
can occur in patients with rosacea, the menopause, hypoglycaemia,
pancreatic tumours, and some medication such as metronidazole,
nitrofurantoin and, sulphonamides, chlorpropamide, and some cephalosporins.
Alcoholic beverages
are complex
As well as ethanol, alcoholic beverages contain a complex
mixture of grape, yeast, hop, barley or wheat-derived substances,
natural food chemicals (eg. salicylates), wood-derived substances
or preservatives like sodium metabisulphite. Furthermore, "fining
agents" may be used to remove particulate matter. These include
the use of egg protein, milk products, gelatin or seafood proteins
("isinglass" from fish swim-bladders) to fine some wine
and beers.
Asthmatic reactions may occur due to sulphites
(sulphites)
Up to a third of patients with asthma complain that wine will
worsen their asthma, less frequently with beer or spiritis. When
patients wheeze after drinking alcohol, there are a number of
possible reasons. Beer, wine and champagne contain sodium metabisulphite
(additive 220, 221), used as a preservative since Roman times.
Some patients, particularly those with unstable or poorly controlled
asthma, may wheeze when they consume these drinks. In general,
there is more preservative in white wine than red wine, and more
in cask wine than bottled wine. The amount of metabisulphite also
varies from brand to brand. Some "low sulphite" wines
are available, although those with extreme sensitivity may not
be able to tolerate them, as sulphur powder is sometimes dusted
over grapes in the weeks leading up to harvest . Examples of no
added sulphur wines include Hardy's No Added Preservative Wines,
and those from Happs or Botabolar amongst others. Other sources
of metabisulphite include vinegar, pickled onions, dried fruit,
or when dusted onto crustaceans and some restaurant salads or
fruit salads. Even when people complain that wine triggers asthma,
metabisulphite is not always the trigger.
Low /no sulfite wines
As a rule, sulfites are found at higher levels in the cask
wine than bottled wine, and are at much higher concentrations
in white wine than red wine, when natural tannins help preserve
the beverage. Some winemakers in Australia produce wines and state
that they do not add sulfites into the wine. There are various
technical reasons related to winemaking why very low levels of
sulfites might still be present, even when not added to the wine
itself. The author has not personally verified the claims of being
preservative free. Those interested should make inquiries of the
winemaker. The following Australian winemakers produce low / no
sulfite wines. This listing is for information purposes only,
is not exhaustive, should not be interpreted as a recommendation,
and no payment of any kind has been received by the author for
this listing.
Low / no sulfite beers
Some brewers produce beer and state that they do not add sulfites.
There are various technical reasons why very low levels of sulfites
might still be present, even when not added to the product itself.
The author has not personally verified the claims of being preservative
free. Those interested should make inquiries of the brewery. The
following brewers claim to produce low / no sulfite beers. This
listing is for information purposes only, is not exhaustive, should
not be interpreted as a recommendation, and no payment of any
kind has been received by the author for this listing.
Asthma can also be due to enzyme deficiency
Patients with aldehyde dehydrogenase deficiency accumulate
high levels of acetaldehyde after consuming alcohol. Acetaldehyde
has been blamed for asthmatic reactions to alcohol in up to half
of Japanese asthma patients. Sometimes histamine within
alcoholic beverages has been blamed for allergic reactions.
Histamine and other substances may also cause problems
Histamine can trigger sneezing, runny nose and sometimes wheeze,
stomach upset and headache. There is more histamine in red than
white wines, although the amounts will vary from wine to wine.
Some small studies have shown that antihistamines can help reduce
the severity of symptoms, but as the amount of wine challenge
was equivalent to only one glass, probably won't prevent hangovers!
Others substances within wine may also cause problems to some
unlucky individuals, but these are not well defined.
Serious allergic reactions to beer or wine may occur
Anaphylaxis has been described in patients with severe allergic
reactions to proteins within grapes, yeast, hops, barley and wheat.
These patients are not sensitive to alcohol itself.
Anaphylaxis to alcohol is rare
Allergic reactions to alcohol itself are rare, but described
in a few dozen published case reports. As little as 1 ml of pure
alcohol (equivalent to 10ml of wine or a mouthful of beer) is
enough to provoke severe rashes, difficulty breathing, stomach
cramps or collapse, a condition known as anaphylaxis. Given that
the body constantly produces small amounts of alcohol itself,
the reason that such reactions occur is poorly understood.
Mechanisms of alcohol allergy
The mechanism of allergic reactions to alcohol is uncertain.
It is not thought to be IgE mediated, and it is likely that the
breakdown products of alcohol such as acetic acid or acetaldehyde
are unlikely to trigger allergic reactions either. Hypotheses
include contaminants with alcohol, happen carrier responses, alcohol
or metabolite conjugates.
Allergy testing of patients with suspected alcohol allergy
In published case reports, all patients thus far have had
negative skin test to ethanol. Some have had positive skin prick
testing to acetic acid or acetaldehyde but not always, and some
have had allergic reactions on challenge to alcohol, acetic acid
or both. Some patients who have had positive reactions to acetic
acid on skin testing, yet have had negative challenges. Finally,
alcohol can sometimes act as a "co-factor", increasing
the likelihood of anaphylaxis from other causes.
Sources of alcohol are not always obvious
When one thinks of alcohol sensitivity, beverages come immediately
to mind. There are however, potentially a number of other less
obvious sources. These include as alcoholic soft drinks, mixes,
spiked drinks, food marinades or tomato puree. Over-ripe fruit
can ferment, resulting in enough alcohol production to trigger
a reaction. Some medicines like cough syrups also contain alcohol,
as do some medicines given by injection.
Management of alcohol allergy
Accidental exposure may lead to unexpected reactions. Patients
with alcohol allergy should be managed in the same way as others
with serious allergic reactions: identify and avoid the cause,
wear a MedicAlert bracelet, and carry adrenaline (epinephrine)
as part of an emergency action plan if they are at risk of dangerous
allergic reactions in the future.
Milder reactions to alcohol may also occur
Alcohol can worsen symptoms in patients with hives / urticaria.
Occasionally, alcohol can also trigger hives directly. As with
more serious allergic reactions, the mechanism is unclear. Less
common reactions include localised contact hives and contact dermatitis.
Not all adverse reactions to alcohol are due to allergy
Other effects of alcohol toxicity are well known, including
its effect on the liver, stomach, brain and mental functioning
in large amounts. Even though alcohol has a relaxant effect on
the brain, some individuals will experience paradoxical agitation
and anxiety. Such symptoms are due to the drug-like activity of
alcohol. They do not represent "allergy" anymore than
a "hangover" does.
References
Ayres, J. G. and D. Allsopp. Fungal growth on wine corks--a
potential source of exposure to susceptible individuals. Clin
Exp Allergy 1994; 24(12): 1179-80.
Boehncke W-H, Gall H. Ethanol metabolite acetic acid as causative
agent for type-I hypersensitivity-like reactions to alcoholic
beverages. Clin Exp Allergy 1996; 26: 1089-91.
Bonadonna, P., M. Crivellaro, et al. Beer-induced anaphylaxis
due to barley sensitization: two case reports." J Investig
Allergol Clin Immunol 1999; 9(4): 268-70.
Clayton, D. E. and W. Busse. Anaphylaxis to wine. Clin Allergy
1980; 10(3): 341-3.
Curioni A et al. Urticaria from beer: an immediate hypersensitivity
reaction due to a 10kDa protein derived from barley. Clin Exp
Allergy 1999; 29: 407-13.
Dahl, R., J. M. Henriksen, et al.Red wine asthma: a controlled
challenge study. J Allergy Clin Immunol 1986; 78(6): 1126-9.
Dalton-Bunnow, M. F. Review of sulfite sensitivity. Am J Hosp
Pharm 1985; 42(10): 2220-6.
Ehlers, I., U. C. Hipler, et al. "Ethanol as a cause of hypersensitivity
reactions to alcoholic beverages." Clin Exp Allergy 2002;
32(8): 1231-5.
Elphinstone PE et al. Alcohol-induced urticaria. J Royal Soc Med
1985; 78: 340-1.
Fernandez-Anaya, S., J. F. Crespo, et al.Beer anaphylaxis. J Allergy
Clin Immunol 1999; 103(5 Pt 1): 959-60.
Figueredo, E., S. Quirce, et al. Beer-induced anaphylaxis: identification
of allergens. Allergy 1999; 54(6): 630-4.
Garcia-Casado, G., J. F. Crespo, et al. Isolation and characterization
of barley lipid transfer protein and protein Z as beer allergens.
J Allergy Clin Immunol 2001; 108(4): 647-9.
Garcia-Robaina, J. C., F. de la Torre-Morin, et al. Anaphylaxis
induced by exercise and wine. Allergy 2001; 56(4): 357-8.
Gershwin, M. E., C. Ough, et al. Grand rounds: adverse reactions
to wine. J Allergy Clin Immunol 1985; 75(3): 411-20.
Gotz, M. Pseudo-allergies are due to histamine intolerance. Wien
Med Wochenschr 1996; 146(15): 426-30.
Halpern, G. M., M. E. Gershwin, et al. The effect of white wine
upon pulmonary function of asthmatic subjects. Ann Allergy 1985;
55(5): 686-90.
Harada S et al. Aldehyde dehydrogenase deficiency as cause of
facial flushing reaction to alcohol in Japanese. Lancet 1981;
982.
Imai, K., T. Tokuno, et al. A case of food-dependent anaphylaxis
induced by alcohol Arerugi 1992; 41(9): 1419-22.
Kelso, J. M., M. U. Keating, et al. Anaphylactoid reaction to
ethanol. Ann Allergy 1990 64(5): 452-4.
Kleinhans, D. Sensitivity of asthma patients to sulfur compounds
in food, wine and injection solutions. Dtsch Med Wochenschr 1990;
107(37): 1409-11.
Kochumian, A. A., R. R. Bedzhieva, et al. 3 cases of death in
bronchial asthma patients after consuming alcoholic beverages.
Ter Arkh 1987; 59(1): 110-1.
Mallon, D. F. and C. H. Katelaris. Ethanol-induced anaphylaxis
following ingestion of overripe rock melon, Cucumis melo. Ann
Allergy Asthma Immunol 1997; 78(3): 285-6.
Ormerod AD, Holt PJA. Acute urticaria due to alcohol. Br J Dermatol
1983; 108: 723-4.
Pastorello EA et al. Identification of grape and wine allergens
as an Endochitinase 4, a lipid-transfer protein, and a Thaumatin.
J Allergy Clin Immunol 2003; 111: 350-9.
PrzybillaB, Ring J. Anaphylaxis to ethanol and sensitization to
acetic acid. Lancet 1983; 483.
Reed TE et al. Alcohol and acetaldehyde metabolism in Caucasians,
Chinese and Amerinds. CMA Journal 1976; 115: 851-5.
Sticherling, M. and J. Brasch. Alcohol: intolerance syndromes,
urticarial and anaphylactoid reactions. Clin Dermatol 1999; 17(4):
417-22.
Ting, S. Anaphylactoid reaction to ethanol. Ann Allergy 1992;
69(5): 463.
Tsevat, J., G. N. Gross, et al. Fatal asthma after ingestion of
sulfite-containing wine. Ann Intern Med 1987; 107(2): 263.
Vally, H., A. Carr, et al. Wine-induced asthma: a placebo-controlled
assessment of its pathogenesis. J Allergy Clin Immunol 1999; 103(1
Pt 1): 41-6.
Vally, H., N. de Klerk, et al. Alcoholic drinks: important triggers
for asthma. J Allergy Clin Immunol 2000; 105(3): 462-7.
Vally, H. and P. J. Thompson (2001). "Role of sulfite additives
in wine induced asthma: single dose and cumulative dose studies."
Thorax 56(10): 763-9.
Wantke, F., M. Gotz, et al. The red wine provocation test: intolerance
to histamine as a model for food intolerance. Allergy Proc 1994;
15(1): 27-32.
Wantke, F., W. Hemmer, et al. Histamine in wine. Bronchoconstriction
after a double-blind placebo-controlled red wine provocation test.
Int Arch Allergy Immunol 1996; 110(4): 397-400.
Wright, W., Y. G. Zhang, et al. Effect of inhaled preservatives
on asthmatic subjects. I. Sodium metabisulfite. Am Rev Respir
Dis 1990; 141(6): 1400-4.
Wuthrich, B. and T. Huwyler. Asthma due to disulfites. Schweiz
Med Wochenschr 1989; 119(35): 1177-84.
Zellweger, J. P. Asthma and rhinitis induced by the ingestion
of pure ethanol and by the inhalation of alcohol vapors]."
Schweiz Med Wochenschr 1982; 112(6): 212-4.
Vally H, Thompson PJ. Alcoholic drinks and asthma (Review).
Clin Exp Allergy 2002; 32: 186-91.
