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Biogenic amines
  • Histamine intolerance
    • Wine contains histamine (red > white), and alcohol inhibits intestinal diamine oxidase which metabolizes histamine
    • Beer may also contain histamine in varying amounts
  • Biogenic amines other than histamine: most commonly implicated are tyramine and phenylethylamine (both associated with headache)

  • Wine contains large amount of sulfites (>100 ppm)
  • Sulfite sensitivity may cause bronchoconstriction or wheezing
Alcohol intolerance due to decreased aldehyde dehydrognase2 (ALDH2) activity
  • Build up of acetaldehyde due to decreased enzyme activity causes degranulation of mast cells, usually causing a nonelevated, intense erythema to appears over the face and trunk within minutes (usually peaking at 30 min), sometimes with associated nausea, light-headedness, headache, nasal congestion, bronchoconstriction
  • Genetic deficiency: single nucleotide polymorphism (ALDH2*504lys) of acetaldehyde dehydrogenase affects 40% of East Asians (nearly absent in whites), known as "Asian flush, blush, or glow"
  • Inhibition by drugs: disulfiram (Antabuse), ketoconazole, griseofulvin, topical tacrolimus, chlorpropamide, cephalosporins cause similar symptoms as genetic deficiency
IgE-mediated reaction to allergens in the alcoholic beverage
  • Wine proteins
    • Grape (Vitis vinifera) proteins
      • Endochitinase 4A
      • Thaumatin-like protein
      • Vit v 1 (LTP1), which is homologous to peach LTP
      • Grape chitinases, thamautin proteins, and LTP are thought to withstand vinification
    • Fungi involved in fermentation or present on grapes (e.g. noble rot with Botrytis cinerea)

    • Wine contaminated with food proteins used to clarify (fine) wine: egg white (lysozyme, albumin), fish (protein contaminating isinglass fish gelatin), cow's milk (casein), tree-nuts (tannins)
      • Studies demonstrate that this is a very unlikely cause of an allergic reaction to wine even in patients allergic to egg, fish, milk, nuts

    • Hymenoptera venom - insects incidentally pressed with grapes causing a reaction when grape juice/wine ingested by venom-sensitized patients
      • Occurs only with grape juice or fresh wine because venom allergens degrade with time, and sensitivity is specific to that batch of venom-contaminated juice/wine

  • Beer proteins
    • Grains, e.g. barley, wheat
    • Beer allergens may include those in the LTP family (stable during brewing process)
    • Fungi involved in fermentation
    • Hops have been suspected as an allergen in beer reaction but there are no cases showing a causative relationship

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