Possible allergic reaction to beer
I would like help in the evaluation and management of a patient who had a reaction to ingested beer (Shiners and Miller Light) in January and most recently early this month. He was at an airport in January and had a Shiners Beer and within 15 minutes developed nasal congestion, hoarseness and chest tightness along with sneezing spells. These symptoms resolved within 1-2 hrs after taking a Claritin. Early this month at the Mavericks game he had a similar episode after drinking Miller Light. This time his symptoms resolved spontaneously in about two hours although he was uncomfortable with the symptoms. His diet has not changed and he does not think it is a food item that triggered this episode. He had flushing but no hives or angioedema.
He does have a history of anaphylaxis to Motrin and avoids all NSAIDS currently. He would like to know if there is any specific ingredients in the beer that could be causing these symptoms and whether he should avoid all beers in the future. Thanks.
Thank you for your inquiry.
Trying to find the culprit of a possible allergic reaction to beer is a difficult task. There are many reported sources of allergic or allergic-like reactions to beer. These include contents in the beer itself including the alcohol, hops, barley, acetic acid, and other ingredients within the beer. Testing can be complex, and oftentimes skin tests are not useful and oral challenges need to be performed if the patient wishes to continue consuming beer or other alcoholic beverages.
There is a fairly rich bibliography regarding reactions to alcohol as well as other contents in beer, and for your convenience, I have copied below some references as well as abstracts which discuss this issue in more detail.
Basically, the most frequent causes of reaction to beer are IgE-mediated reactions to barley/hops or a reaction to the alcohol itself, which is quite often due to acetaldehyde dehydrogenase 2 deficiency. Acetaldehyde dehydrogenase 2 is the enzyme that metabolizes the first metabolic product of alcohol digestion, acetaldehyde. When acetaldehyde accumulates, it produces mast cell degranulation, and therefore its symptoms mimic an allergic response.
Of course, if this is the case, your patient will react adversely to any alcoholic beverage. If they do not -- for example, if they can drink hard liquor or wine -- then that rules out this disorder, and one would search next for IgE-mediated responses to other ingredients. The bibliography below contains examples of cases where other culprits have been identified. The protocols for skin testing, et cetera, are contained within these articles. Also below are the responses to similar questions sent to our website. These will be helpful to you as well. To access them simply go to our site and type "beer" into the search box.
However, I must admit that personal experience in dealing with patients who have this type of reaction to beer indicates that on many occasions it isn't possible to identify a specific culprit.
Thank you again for your inquiry and we hope this response is helpful to you.
1. Haden JR and Khan DA. Remission of anaphylactoid reaction to alcohol. J Allergy Clin Immunol, February 2003; 111(1):S98-S99 (abstract).
2. Takao A, et al. Correlation between alcohol-induced asthma and acetaldehyde dehydrogenase-2 genotype. J Allergy Clin Immunol 1998; 101(5):576-580.
3. Ehlers I, et al. Ethanol as a cause of hypersensitivity reactions to alcoholic beverages. Clin and Expe Allergy 2002; 32(8):123-125.
4. Kelso JM, et al. Anaphylactoid reaction to ethanol. Annals of Allergy 1990; 64(5):452-454.
5. Ormerod AD and Holt PJA. Acute urticaria due to alcohol. Br J Derm 1983; 108:723-724.
6. Przybilla B and Ring J. Anaphylaxis to ethanol and sensitization to acetic acid. Lancet 1983; 483.
7. Sticherling M and Brasch J. Alcohol: Intolerance syndromes, urticarial and anaphylactoid reactions. Clin Dermatol 1999; 17(4):417-422.
8. Timg S. Anaphylactoid reaction to alcohol. Annals of Allergy 1992; 69(5):463.
Isr Med Assoc J. 2009 Jun;11(6):380-1. Beer anaphylaxis. Nusem D, Panasoff J
Allergol Int. 2006 Dec;55(4):411-4.
Urticarial reaction caused by ethanol.
Nakagawa Y, Sumikawa Y, Nakamura T, Itami S, Katayama I, Aoki T.
Osaka Kouseinenkin Hospital, Osaka-city, Japan.
Background: We report a case of an urticarial reaction after drinking alcohol beverages. The patient was a 47-year-old man suffering urticarial and anaphylactoid reaction to alcohol for two years. These reactions were observed at every alcohol beverages intake.
Case Summary: We performed a prick test with diluted ethanol, alcohol beverages and their metabolites (acetaldehyde, acetic acid). Only acetic acid showed a positive result. Oral challenge test with diluted-ethanol caused pruritus and swelling of his lips. An oral challenge test with 8% diluted Shochu (Japanese distilled alcohol from rice or wheat) caused wheals on his upper back.
Discussion: Only acetic acid, a metabolite of alcohol, induced a positive prick test in the patient with alcohol-induced urticaria. This result was not observed in normal volunteers. An oral challenge test with diluted-alcohol or Shochu showed a positive wheal reaction in a dose dependent-manner which suggests that urticaria seen in this patient might be induced by alcohol-intolerance. However possible allergic reaction to acetaldehyde could not be excluded.
Phil Lieberman, M.D.