Concern for allergy to beer

Approximately two years ago, patient ingested a wheat beer, which he immediately reacted to causing swelling of his lips, his eyes, and his throat as well as itching down his throat. He was then given Benadryl, which slowly resolved his symptoms. He did not have any hives or flushing at that time. After that, he did not have any other experience with other types of beer and just chose to avoid Belgian beers until about six months ago, he had a pale ale style brewing which elicited the same response of swelling of especially his lips and his eyes and throat. He then was given Benadryl, which really resolved his symptoms. He went to see his physician after that and was prescribed an EpiPen for further interactions with this reaction. He has always drink beer and in fact even fruit beer in the past with no problems at all. He also has never had reaction with wine or other mouth liquors. In the 1980s, he was growing corn with his wife and had a similar reaction while walking down the corn fields at high pollen season, but has never had anything like this before or after that with corn.

He does have seasonal allergies that bother him intermittently. He was on allergy injections for at least a few years in the past and his allergy symptoms are a lot better since then. He just uses nasal sprays and over-the-counter medications when needed for his allergies. They do not bother him much at this time.

He does complain of itchy, red, and tearing eyes and light hurts his eyes and eyelid swelling. This occurs when he has his allergic reaction as well as due to seasonal allergies when he has his outbreak.

He also has been diagnosed with an exercise-induced asthma and mild intermittent asthma causes mild-to-moderate wheezing episodes especially when he is sick with an illness. It does tend to limit his exercise and play during or after exercise in which he uses an albuterol inhaler prior to exercising. He feels tightness in chest and sometimes wheezing. When he is sick, he will usually use Mucinex as well as albuterol that helps, but he tends to have the sickness go straight to his lungs as in the past he has used prednisone as a kid for asthma flares and has also used cromolyn sodium which he does not think helped. He admits to coughing spells occasionally and when sick, coughing up mucus, shortness of breath, coughing on exertion, coughing when lying down, and coughing with wheezing and laughing. He does not complain of lung problems as long as he is not sick. When he is sick is when these things occur.

ASSESSMENT:
1. Concern for allergy to beer.
2. Allergic rhinosinusitis.
3. Allergic conjunctivitis.
4. Mild intermittent asthma.
5. Exercise-induced asthma.
6. Infection-induced asthma.

PLAN:
1. We will further investigate his allergy to beer with a RAST ImmunoCAP testing to barley, brewer’s yeast and, hops. We will also do a serum tryptase level to assess for genetic anaphylaxis disorder although he has no family history of a mast cell disorder.
2. We will prescribe Asmanex 200 mcg two puffs twice daily on onset of sickness and he will continue that five days after sickness resolves and then go down to one puff twice a day for five days thereafter and then discontinue. We will see if this helps in clear infection easier and resolves some of his asthma symptoms at that time.
3. We will call him with the results of the RAST testing and serum tryptase level and further assess his condition at that time. We discussed the possibility of finding an unidentifiable result of an allergy to beer, but I have told him to avoid beer at this time and always carrying EpiPen. He is concerned about possibility of this growing into an allergy to wine and mouth liquors which we discussed is probably unlikely, but to carry the EpiPen just in case at that time also.

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