Ethanol-Induced Urticaria: Elevated Tryptase Levels after Double-Blind, Placebo-Controlled Challenge

Abstract

We present a 48-year-old patient who complained for 1 year about urticarial reactions which appeared always when he ingested alcoholic beverages. Skin prick tests with ethanol were negative but positive with 10% acetic acid in the patient. Normal controls tested negative with acetic acid. Skin prick tests to common immediate-type allergens were negative. The patient underwent a double-blind, placebo-controlled challenge test. A few minutes after challenge with ethanol but not with placebo, the patient developed erythema and wheals on the chest and the upper arms. The tryptase serum level rose from undetectable (0.1 U/ml) before challenge to 3.8 U/ml after skin lesions had appeared. This case demonstrates that increased tryptase serum levels can help in the diagnosis of ethanol-induced urticaria.

Two Case Reports of Life-Threatening Ethanol-Induced Anaphylaxis

“…Serum tryptase is detected 60–90 min after the onset of anaphylaxis and persists for up to 5 h [20]. As shown in both our study and that of Emonet et al [3], serum total tryptase increased following the development of symptoms after an ethanol challenge. It must be noted, however, that elevated serum total tryptase levels are uncommonly found in food-related anaphylaxis for reasons which are not fully understood [21].…”

“…As illustrated by our first case, such reactions appear to be precipitated by relatively small quantities of ethanol, and 1 ml may be sufficient to provoke severe anaphylaxis [1, 16]. Degranulation of mast cells occurs during such episodes as demonstrated in skin biopsies of urticarial lesions and the rise in serum histamine [17] and total tryptase levels [3]. Serial measurement of serum total tryptase is the most commonly used method of detecting and confirming anaphylaxis and is more reliable than histamine because of its stability and longer biological half-life [18].…”

“…On a separate occasion, she developed urticaria after consumption of 0.4 ml of 96% ethanol. A double-blind placebo-controlled challenge containing either 20 ml of 96% ethanol in 300 ml of sweetened grape juice or sweetened grape juice alone [3] resulted in generalised urticaria after 7 ml of the ethanol mixture was consumed. This reaction was accompanied by a rise in serum total tryptase from a non-detectable level at baseline to 13.5 ng/ml 1 h after the onset of symptoms.…”

Prevalence of self‐reported hypersensitivity symptoms following intake of alcoholic drinks

“…Cases and case series of urticarial and anaphylactoid reactions following ethanol intake have been reported [17,[51][52][53][54]]. An ethanol challenge performed in a patient with ethanol-induced urticaria resulted in urticaria and an increase in plasma histamine.…”

Incremental build‐up food challenge – a new diagnostic approach to evaluate pseudoallergic reactions in chronic urticaria: a pilot study

“…Pseudoallergens evoking or enhancing urticaria are artificial food dyes, preservatives and sweeteners [11,12,19,20], aromatic volatile compounds in tomatoes, herbs and wine [21] or other phenolic substances such as salicylic acid, p-hydroxy benzoic acid, anethole, ethyl vanillin, citron oil and orange oil [11,12,22,23]. Alcohol and high dietary fat intake have been also described to elicit urticaria [10,[24][25][26]. The use of newly developed flavourings and food additives by the food industry is common, changes rapidly, and is not adequately reflected in the standardized capsule tests.…”