© 1998 S. Karger AG, Basel 1018–8665/98/1972–0181$15.00/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch This article is also accessible online at: www.karger.com http://BioMedNet.com/karger S. Emonet a S. Hogendijk a J. Voegeli b P.A. Eigenmann a, c N. Roux a C. Hauser a, d a Allergy Unit, Division of Immunology and Allergy, b Department of Community Medicine and c Department of Pediatrics, University Hospital, Geneva, and d Department of Dermatology and Venereology of Western Switzerland, Geneva/Lausanne, Switzerland Case Report Dermatology 1998;197:181–182 Ethanol-Induced Urticaria: Elevated Tryptase Levels after Double-Blind, Placebo-Controlled Challenge Introduction Ethanol may induce various kinds of adverse skin reactions such as flushing and, rarely, immediate-type hypersensitivity-like reactions [1, 2]. Anaphylaxis related to eth- anol intake appears to be exceptionally rare [3, 4]. We report the case of a patient who pre- sented urticaria after a double-blind, placebo- controlled challenge test with ethanol and an increased serum tryptase level. Case Report For 1 year, a 48-year-old man complained about burning sensations in the hands and feet a few minutes after ingestion of various kinds of alcoholic but not following nonalco- holic beverages. He reported that he had recently started to experience itching and to develop a rash on his face after every con- sumption of even small amounts of alcohol. He denied any other systemic symptom and indicated to tolerate the ingestion of vinegar. He had no personal history of atopy. Skin prick tests to frequent aeroallergens were negative. Darier’s sign was negative. Skin prick tests with ethanol (9.6 and 96%) and acetic acid (0.5 and 10% vol/vol) were performed as described [4]. All tests were negative in 3 healthy controls. The patient tested negative except for a +++ reaction to 10% acetic acid. A double-blind, placebo- controlled challenge with 20 ml ethanol 96% (vol/vol) diluted in 300 ml of sparkling grape juice with sugar as challenge vehicle and ve- hicle alone was performed. It had previously been confirmed that the ethanol-containing juice could not be distinguished from the juice without ethanol. Five minutes after in- gestion of ethanol the patient developed a burning sensation, facial erythema and, a few minutes later, urticarial lesions on his chest and upper arms. No dyspnea or hypotension was noted. Serum tryptase determined by the FEIA kit (Pharmacia, Uppsala, Sweden) be- fore challenge was nondetectable, 3.8 U/ml 10 min after the challenge when urticarial lesions appeared and again nondetectable 3 and 5 h after the challenge (detection limit 0.1 U/ml). The challenge with juice contain- ing no ethanol was negative and not followed by tryptase determination. The patient re- fused further investigations and treatment. Discussion Adverse reactions to alcoholic beverages are well known. Reactions may occur either to constituents other than ethanol and to ethanol itself. Besides drunkenness, the most frequent reaction to ethanol is flushing. Ethanol can accentuate or trigger flushing of various etiology such as physiologic flushing (erythema pudicum), postmenopausal flush- ing, flushing due to rosacea and flushing due to systemic disorders such as mastocytosis or carcinoid syndrome. Ethanol has been reported to trigger flushing in patients taking a variety of drugs such as metronidazole, griseofulvin, ketoconazole, chloramphenicol, quinacrine, cefamandole, cefoperazone, mox- alactam or calcium carbamide. Patients on disulfiram medication are particularly prone to flushing and other general symptoms, even with very small amounts of ethanol. Ethanol triggered flushing in patients taking chlor- propamide appears to be dominantly inher- ited [5] and can be prevented by acetyl sali- cylic acid [6]. Flushing due to genetically decreased activity of aldehyde dehydro- genase isoforms is well known in Asians. Besides flushing, ethanol intake can trigger asthma attacks, as frequently observed in Conrad Hauser Allergy Unit, Hôpital Cantonal Universitaire CH–1211 Geneva 14 (Switzerland) Tel. +41 22 372 9381, Fax +41 22 372 9416 E-Mail hauser@cmu.unige.ch oooooooooooooooooooooooooooooooooooooooooooo Key Words Alcohol Anaphylaxis Tryptase ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo 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 neg- ative 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. oooooooooooooooooooo Received: December 16, 1997 Accepted: March 16, 1998 Downloaded by: Columbia University 128.59.222.107 - 12/6/2018 6:16:11 AM