Q:

12/20/2011
A patient report a sensation of throat closing, increased salivation and on occasion a hoarse voice with certain beer and white wine ingestions. Guinness does not seem to bother him. He has an Epi-pen and when he experiences any of these symptoms he stops drinking the aforementioned beverages. No problem with liquor. He is Asian-no flushing no wheezing. He was tested for wheat, malt, barley, hops, white grape, botrytis and saccharomyces cerevisiae-which was the only positive Are there any other products that should be avoided besides beer and wine?

A:

Thank you for your inquiry.

I think that you have done relatively good due diligence, especially regarding the workup for the patient who has an allergic-like reaction to beer. However, wine is a far more complex culprit, and there are other putative agents in wine that have been incriminated. It is a very complex issue, and in my experience, one is very rarely able to identify any specific agent in patients such as the one you described. Also the history of reacting to white wine and beer, but not other alcoholic preparations is puzzling since I know of no allergen that would normally be shared between them.

Just to illustrate the complexity of the issue, I have copied below a number of abstracts along with a reference. We also have a couple of entries on the Academy’s Ask the Expert website that can be reviewed by simply typing “wine” into the search box.

In summary, it is very unlikely, at least in my experience, that you will be able to identify a culprit that is responsible for these reactions, especially one that would be common to both white wine and beer. However, it may be helpful for you, if for no other reason than to illustrate the difficulties involved, to peruse the references below and the previous website entries to the Ask the Expert website regarding these issues.

Thank you again for your inquiry and we hope this response is helpful to you.

F. Borghesan Allergy to Wine Allergy Volume 59, Issue 10, pages 1135–1136, October 2004
Journal of Allergy and Clinical Immunology
Volume 111, Issue 2, February 2003, Pages 350-359 Mechanisms of Allergy
Identification of grape and wine allergens as an Endochitinase 4, a lipid-transfer protein, and a Thaumatin
Elide A. Pastorello MDa, Laura Farioli BScb, Valerio Pravettoni MDa, Claudio Ortolani MDc, Donatella Fortunato BScd, Maria Gabriella Giuffrida BScd, Lorenza Perono Garoffo BScd, Ambra Marianna Calamari MDa, Oreste Brenna PhDe, Amedeo Conti PhDd
From athe Allergy Center, First Division of General Medicine, Ospedale Maggiore IRCCS, Milan; bUOOML, CEMOC, I.C.P., Milan; cBizzozzero Division, Niguarda Ca' Granda Hospital, Milan; dNational Research Council, ISPA, Turin; and ethe Department of Food Science and Microbiology, University of Milan, Milan.
Received 9 April 2002; revised 20 May 2002; Available online 9 April 2003.
Abstract
Background: Few allergic reactions to grape are reported in the literature. In some cases an association with peach and cherry allergy was observed. No IgE-mediated reactions to wine have been described, and no grape major allergens have yet been identified.
Objective: We describe several severe reactions to grape or wine. We characterized the grape major allergens and tried to identify the allergen in wine. Methods: We collected documented histories of allergic reactions to grape and wine. Grape allergens were identified by means of SDS-PAGE and immunoblotting and purified by means of HPLC. Using amino acid sequencing and mass spectrometry, we identified the family of proteins to which the allergens belong. Cross-reactivity with peach and cherry was evaluated by means of cross-wise inhibition experiments.
Results: Eleven patients with reactions to grape and 3 with anaphylactic reactions to wine were recruited. The major allergens were an endochitinase 4A and a lipid-transfer protein (LTP) that was homologous to and cross-reactive with peach LTP. A 24-kd protein homologous to the cherry thaumatin-like allergen was a minor allergen. Endochitinase 4A is very likely the allergen in vino novello and in vino Fragolino.
Conclusions: Grape and wine might cause severe allergic reactions in sensitive patients. The major allergens of grape are endochitinase 4A, which is also the allergen of wine, and an LTP cross-reacting with the peach major allergen. (J Allergy Clin Immunol 2003;111:350-9.)

Food Addit Contam Part A Chem Anal Control Expo Risk Assess. 2011 Apr;28(4):408-16. Epub 2011 Feb 16.
Levels of histamine and other biogenic amines in high-quality red wines.
Konakovsky V, Focke M, Hoffmann-Sommergruber K, Schmid R, Scheiner O, Moser P, Jarisch R, Hemmer W.
Source
FAZ - Floridsdorf Allergy Centre, Franz Jonas Platz 8/6, A-1210 Vienna, Austria.
Abstract
Biogenic amines in wine may impair sensory wine quality and cause adverse health effects in susceptible individuals. In this study, histamine and other biogenic amines were determined by HPLC after amine derivatisation to dansyl chloride conjugates in 100 selected high-quality red wines made from seven different cultivars. Amine levels varied considerably between different wines. The most abundant amines were putrescine (median = 19.4 mg l(-1), range = 2.9-122), histamine (7.2 mg l(-1), 0.5-26.9), and tyramine (3.5 mg l(-1), 1.1-10.7), whereas lower levels were found for isoamylamine (median = 0.25 mg l(-1)), phenylethylamine (0.16 mg l(-1)), cadaverine (0.58 mg l(-1)), spermidine (1.8 mg l(-1)) and tryptamine (0.06 mg l(-1)). Positive correlations were observed between isoamylamine and phenylethylamine, and between histamine, putrescine and tyramine levels. Amine concentrations were similar in all wine cultivars except Pinot noir and St. Laurent wines, which showed significantly higher tryptamine and cadaverine levels. The results indicate that levels of histamine and other biogenic amines may vary considerably between red wines independent of grape variety and that high amounts can also be found in high-rated wines. Adopting a legal histamine threshold level of 10 mg l(-1) in the European Union, as formerly introduced in other countries, would have excluded 34% of the investigated wines from the market.

Curr Opin Allergy Clin Immunol. 2008 Jun;8(3):266-9.
Adverse reactions to wine: think outside the bottle.
Armentia A.
Source
Allergy Section, Río Hortega Hospital, Valladolid, Spain.
Abstract
Purpose of Review: Wine contains chemical and biological contaminants. Symptoms such as facial flushing, asthma and oral allergic swelling and burning (oral syndrome) have been attributed to these contaminants and food additives. Their clinical implications should be known.
Recent Findings: Recent studies have reported a high prevalence of hypersensitivity symptoms after intake of alcoholic drinks in the general population. Red wine was the most common beverage implicated. Wine contains many contaminants. Some of them come from Hymenoptera insects that fall into the wine when grapes are collected and pressed. We have found patients with allergic symptoms related to wine consumption who are sensitized to Hymenoptera venom without previous stings. The aim of this study is to assess the potential importance of their sensitization to Hymenoptera antigens as the cause of their symptoms and also to comment on other recent studies on wine hypersensitivity.
Summary: We found patients with allergic symptoms related to wine consumption who are sensitized to Hymenoptera venoms. Challenges were negative with sulfites, other additives and aging wines, but positive with young wines. Sera from all the patients detected Hymenoptera venom antigens. We report the first cases of sensitization to venom antigens by the oral route.

Allergy. 1999 Jun;54(6):630-4.
Beer-induced anaphylaxis: identification of allergens.
Figueredo E, Quirce S, del Amo A, Cuesta J, Arrieta I, Lahoz C, Sastre J.
Source
Fundación Jiménez Díaz, Servicio de Alergología, Universidad Autónoma de Madrid, Spain.
Abstract
Background: We report on a 21-year-old atopic woman who developed urticaria, angioedema of the face, and wheezy dyspnea shortly after drinking beer and after eating a corn-made snack.
Methods: Skin prick tests and specific IgE determinations to beer ingredients and cereal extracts were performed. Immunoblotting inhibition assays were carried out to investigate possible common allergens shared by barley and malt with corn.
Results: Skin prick tests and specific IgE measurements with beer, barley, malt, wheat, corn, rye, rice, and oat flour were positive. Ten pollen-allergic patients showed negative skin tests to beer. Double-blind, placebo-controlled, oral challenge tests with sodium metabisulfite and wheat flour were negative. Immunoblotting demonstrated several IgE-binding bands at 31-56 kDa in malt and barley extracts, and a major band at 38 kDa in the beer extract. Immunoblot inhibition assays showed that malt extract was able to inhibit most of the IgE-binding bands in wheat and corn extracts, whereas corn did not produce significant inhibition to barley and malt extracts.
Conclusions: This patient developed type I hypersensitivity to barley/malt and corn. Although she also showed IgE reactivity to wheat and other cereals, no symptoms were elicited upon ingestion of these cereals, probably indicating latent sensitization to them.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology