Polyphenolic Activation of Basophils Explains Alcohol Hypersensitivity in AERD

ABSTRACT

Objective

Alcohol hypersensitivity (AH), an exacerbation of respiratory symptoms in response to alcohol consumption, is common in aspirin‐exacerbated respiratory disease (AERD) and other forms of chronic rhinosinusitis (CRS). The mechanism of this is unknown. This study investigates the ability of polyphenolic compounds in alcoholic beverages to activate innate immune cells as a means of explaining AH in AERD.

Methods

Data were collected from 478 consecutive adults presenting to a tertiary care sinonasal clinic in whom the presence of AH and their CRS phenotype was determined. A subset of these individuals was invited to provide whole blood samples on which the effects of ethanol, red wine extract (RWE), and individual polyphenolic compounds were explored. Granulocyte activation was quantified by flow cytometry as upregulation of CD63 during the Basophil Activation Test (BAT). Additionally, secretion of lipid metabolites was measured by enzyme immunoassays (EIAs).

Results

Twelve patients with CRSwNP were compared to age and sex‐matched healthy controls. A dose‐dependent stimulation of basophil degranulation was noted with RWE and epigallocatechin (p < 0.05). No activation was noted in healthy controls or subjects to ethanol. Catechin demonstrated a dose‐dependent, but only near‐significant difference (p = 0.07) in basophil degranulation compared to controls.

Conclusions

Polyphenolic compounds, and not ethanol, can trigger the activation and degranulation of eosinophils and basophils, and this may explain the sensitivity to alcoholic beverages seen in patients with AERD and CRSwNP.

Level of Evidence

NA.

The mechanism behind alcohol sensitivity in AERD has not been previously characterized. This study demonstrates the activation of basophils in patients with CRSwNP and AERD by polyphenolic compounds, but not ethanol. Since these compounds can be found in alcoholic beverages in similar frequencies by which they trigger symptoms, this research provides a reasonable explanation for this interesting phenomenon.

1. Introduction

While salicylates have been used for fevers and inflammation since antiquity, acetylsalicylic acid (ASA) was only discovered in 1853. Mass production of Aspirin began in the late 19th century by Bayer, with adverse reactions soon reported by Hirschberg [1] in 1902 and Gilbert [2] in 1911. In 1968, Max Samter [3] published his sentinel research on what has become known as Aspirin‐exacerbated respiratory disease (AERD), or NSAID‐exacerbated respiratory disease (NERD) in Europe, characterized by asthma, nasal polyps (NPs), and aspirin sensitivity. This triad was first acknowledged in a 1922 French language case report by Widal and colleagues [4]. Their description of Widal–Abrami–Lermoyez syndrome noted a young woman who suffered from the triad of maladies in addition to what sounds like an “overlap syndrome” of AERD and NSAID‐induced urticaria/angioedema (NIUA).

AERD is now understood to be an immune dysregulation involving diminished prostaglandin E2 (PGE2) function, elevated levels of cysteinyl leukotrienes (CysLTs), and respiratory exacerbations in response to cyclooxygenase (COX)‐1 inhibition. Cardet et al. [5] highlighted the significant prevalence of sensitivity to alcoholic beverages (up to 83%) in patients with AERD, but a connection to known pathophysiological processes was not apparent. The respiratory reactions that resulted were like those caused by COX‐1 inhibitors but less severe and with quicker onset. These reactions were also observed in aspirin‐tolerant chronic rhinosinusitis (CRS) and/or asthma, but at a lower incidence.

Vally [6] and Cardet [5] found that while all forms of alcohol could trigger a reaction, red wine and beer were more likely to induce symptoms than white wine or distilled spirits, suggesting that the reaction is not driven by ethanol (EtOH) concentration, but likely another component. The correlation between alcohol sensitivity and the presence of polyphenols—compounds known for their anti‐inflammatory properties—has been previously suggested [7]. Polyphenols have also been linked to migraine exacerbations from red wine [8], suggesting a potential involvement in alcohol sensitivity. Prior work identified the role of basophils and eosinophils in AERD [9] with increased reactivity to red wine extract (RWE) [10]. We hypothesize that alcohol hypersensitivity (AH) in AERD and CRS with nasal polyps (CRSwNP) results from the activation and degranulation of basophils and eosinophils in response to polyphenols present in the alcoholic beverages.

2. Methods

Subjects: A total of 478 patients meeting the criteria for CRS from a tertiary care sinonasal clinic were evaluated over a 3‐year period. AH was determined based upon recurrent exposure to alcoholic beverages with consistent respiratory symptoms (dyspnea, nasal congestion, wheezing, etc.). CRS patients were phenotyped by the absence or presence of NPs on endoscopic exam. AERD was diagnosed by respiratory (upper and/or lower airway) symptoms after ingestion of a nonselective COX inhibitor, formal aspirin/NSAID challenge, or an elevated urinary LTE4 (> 241 pg/mg) [11]. Exclusion criteria included having been aspirin desensitized at the time of study, recent use of biologic therapy, 5‐lipoxygenase inhibitors, or systemic corticosteroids within 1 month of enrollment and blood collection. Control subjects were healthy volunteers without CRS, asthma, or alcohol sensitivity.

Activation of basophils and eosinophils by EtOH and RWE: Blood samples from 4 AH patients and 3 controls were selected to assess basophil and eosinophil activation by RWE and EtOH. Heparinized peripheral blood samples (10 mL) were collected and red cells lysed using ammonium chloride. CysLTs and eosinophil‐derived neurotoxin (EDN) levels were measured, and basophil activation was further assessed using the basophil activation test (BAT). N‐Formyl‐Met‐Leu‐Phe (FMLP) was used as a positive control.

Enzyme Immunoassays (EIAs): CysLT (Assay Designs, Ann Arbor, MI) and EDN (MBL, Nagoya, Japan) in culture supernatants were quantified by EIA with detection limits of 26.6 and 0.62 ng/mL, respectively.

Activation of basophils by EtOH, RWE, and representative polyphenols: A second cohort was identified utilizing samples from alcohol‐sensitive patients (n = 12) along with age‐ and gender‐matched healthy control subjects (n = 10). This cohort was used to test basophil activation by EtOH, RWE, and polyphenolic compounds (resveratrol, catechin, epigallocatechin) using BAT.

BAT: Basophil activation was determined by flow cytometry using a commercial BAT (Bühlmann; Amherst, NH) [12, 13]. Blood samples were left in a resting state or activated with ethanol (0.1 and 1.0% v/v), RWE (13 and 65 μg/mL; Seppic, Paris, France; Table 1), resveratrol (22 and 220 ng/mL), catechin (1 and 10 μg/mL; source), and epigallocatechin (1 and 10 μg/mL). Anti‐IgE or fMLP was used as positive controls per the manufacturer's directions (Bühlmann). Cells were stimulated at 37°C for 25 min after which samples were centrifuged, supernatants collected, and cellular pellets analyzed by flow cytometry. Ethanol concentrations reflected typical inebriation (0.1%) levels as well as a much higher concentration (1%). RWE concentrations were calculated based upon content present in one full glass of wine (200 mL) and the assumption of 100% absorption, which would then be diluted across the intravascular volume of distribution (5 L). Similar assumptions were made for resveratrol, catechin, and epigallocatechin [14]. The absorption and bioavailability of polyphenolic compounds are incompletely understood and are likely variable depending on the respective class and conjugation of the specific polyphenol, and this is further influenced by microflora through hydrolyzation or other modifications of the conjugated moieties. The catechins studied in this experiment are all known to be absorbed and reach a maximal plasma concentration at 1.5 h [15].

TABLE 1.

Contents of seppic red wine extract ^a .

Analysis		Results (mg/100 g of powder)
Oligomers	Proanthocyanidole B1	1399
	Proanthocyanidole B2	869
	Proanthocyanidole B3	310
	Proanthocyanidole B4	916
Monomers	Catechin	1513
	Epicatechin	1759
	B2‐3 O gallate	538
	Epicatechin 3O gallate	103
Other phenolic compounds	Chlorgenic acid	544
	P‐coumaric acid	179
	Gallic acid	81
	Resveratrol	171

^a As determined by HPLC analysis.

Flow cytometry: Basophils were distinguished from eosinophils by being CCR3+ with low side scatter (PE‐conjugated anti‐CCR3; Bühlmann) (Figure 1).

FIGURE 1.

Representative flow cytometry. The cytometer was gated on basophils (CCR3‐high, side‐scatter‐low); gating strategy for activated (CD63 + ve) basophils (CCR3‐high, side‐scatter high cells comprise eosinophils). [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

Basophil activation was determined as the upregulation of fluorescein‐conjugated anti‐CD63 basophils (Bühlmann) [13].

Statistical analysis: Chi‐squared tests were used to compare AH sensitivity among cohorts, and paired t‐tests were used for EIA and BAT data with corrections applied for multiple comparison errors.

IRB Approval: The study was approved by the University of Virginia (IRB# 20731 and #14457).

3. Results

Patient Demographics: Of 69 patients identifying as having AH, 12 patients with CRSwNP and AH were enrolled, with ages ranging from 45 to 65 years (mean 57.4 ± 7.9). Of these patients, seven suffered from AERD and the other five were moderate to severe CRSwNP, with an overall average prior number of surgeries of 4.5 ± 3.4. The most common reaction was nasal symptoms, present among all 12 participants, with lower respiratory symptoms noted by only two (both AERD patients). Age and sex‐matched healthy controls were pulled from volunteers. A subset was selected for use in the initial activation studies involving EIAs and eosinophils, comprised of four of the AH patients and three of the controls.

Initial Basophil and Eosinophil Studies: Neither EtOH nor RWE stimulation resulted in a significant difference in CysLTs production between AH and control subjects (Figure 2). EDN release was increased significantly upon exposure to RWE at both concentrations (Figure 3) but not with EtOH. BAT with the initial cohort demonstrated a dose‐dependent activation of basophils with RWE but not with EtOH in patients with AH. This was significant compared to both baseline and between groups (Figure 4).

FIGURE 2.

Cysteinyl Leukotriene (CysLT) production of eosinophils and basophils after stimulation with ethanol (EtOH) and red wine extract (RWE). No significant difference was found between patients with or without alcohol hypersensitivity (AH). AH, alcohol hypersensitivity. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

FIGURE 3.

Eosinophil derived neurotoxin (EDN) release after stimulation with ethanol (EtOH) and red wine extract (RWE). Neither IgE nor EtOH showed a significant difference between patients with or without AH. RWE demonstrated a significant effect at both concentrations tested. AH, alcohol hypersensitivity. FMLP data not shown. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

FIGURE 4.

Basophil activation test results after stimulation with ethanol (EtOH) and red wine extract (RWE). RWE at the high concentration and not EtOH resulted in significantly increased activation of basophils. AH, alcohol hypersensitivity. IgE and FMLP data not shown. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

Subsequent BATs including Polyphenols: In subjects (non‐AH), expected basophil activation occurred after exposure to anti‐IgE and fMLP (latter not shown with mean percent activation of 71.8% and 57.6% for control and AH, respectively), but no significant activation was observed with ethanol, RWE, or the tested polyphenolic compounds (Figure 5). Similarly, no response to ethanol was seen in patients with AH. However, a dose‐dependent stimulation of basophil degranulation was observed with RWE (p < 0.05, RWE at 13 and 16 μg/mL). Of the polyphenols tested, significant activation was observed with epigallocatechin, while resveratrol showed no effect. Catechin showed a trend towards activation but did not reach significance (p = 0.07).

FIGURE 5.

Activation of basophils by polyphenolic compounds. Asterisk represents p < 0.05 compared with control; AH, alcohol hypersensitivity; Cat, catechin; EGC, epigallocatechin; EtOH, ethanol; fMLP, formyl‐methionyl‐leucine‐phenylalanine; ResV, resveratrol; RWE, red wine extract. IgE data not shown. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com]

4. Discussion

Max Samter's1968 paper [3] on AERD noted that, in addition to aspirin, various substances produced reactions. Contrary to Cardet et al. [5], only 14 (7.7%) of his 182 patients noted alcohol sensitivity, similar to the frequency of reactions he found to Yellow Dye No. 5 (tartrazine). Vally and colleagues found that up to 33% of asthmatics [6] and 55% of aspirin‐intolerant patients [16] reported alcohol sensitivity. Cardet and colleagues noted 20% and 51% of lower respiratory symptoms in aspirin‐tolerant asthma (ATA) and AERD, respectively. Unlike prior studies, they also assessed upper respiratory symptoms, finding that 83% of AERD patients and 43% of ATA patients reported some sensitivity to alcohol. Similarly, 43% of patients with CRSwNP noted respiratory symptoms (predominantly upper) compared to our own findings of 68% of AERD and 27% of CRSwNP patients (unpublished data). Given AERD's unique pathophysiology, the AH in CRSwNP may result from a separate process, but its correlation with more severe disease suggests an overlapping process [17]. Both Cardet and Vally noted that the exact mechanism was uncertain.

The studies previously noted by the Vally group [6, 16] reported on the same survey of 366 patients regarding the effects of alcohol and other foods in their asthmatic patients [16]. Patients were also asked about food allergies, specifically to sulfites as determined by reported reactivity to “dried fruits and preserved vegetables which were shown to possess high levels of this additive.” [6] A high correlation was reported between wine and sulfite sensitivity in asthmatics with an odds ratio of 6.59%. They also found a link between wine‐related symptoms and AIA. Vally suggested that the overlap of wine and sulfite sensitivity indicated a strong possibility that sulfites were the cause of those with AH, but no overlap between sulfite and aspirin intolerance. They speculated that salicylate intolerance may play a role, though acknowledging that this was controversial.

Cardet et al. [5] also suggested sulfite sensitivity might be a contributor, but that the broad range of beverages (beer, liquor) with little to no sulfites made the theory less attractive. They referenced Vally's studies showing no difference in symptoms caused by high‐ and low‐sulfite wines, further arguing against this model. Cardet suggests that, given CysLTs' role in AERD, a similar LT‐dependent mechanism could explain alcohol‐induced respiratory reactions. While only an in vitro model, our tests of EtOH and RWE showed no CysLT production, suggesting that CysLT involvement in AH reactions is at least not due to polyphenols. The absence of inducible CysLT production, especially from resveratrol, which inhibits COX‐1, further supports these findings [18]. That AH reactions have not been shown to be life‐threatening, a scenario typically involving CysLTs induced bronchospasm, is further supportive of these observations.

We posited that both Cardet and Vally's work implicated polyphenols as possible triggers for sensitivity [7]. While both noted red wine as the most likely to trigger symptoms, Vally's data indicated that fortifying it did not increase this likelihood. Both also noted that while beer and liquor could trigger a reaction, they were less likely. Data regarding white wine differed: Vally reported a 21.6% reaction rate, with Cardet finding fewer cases. Among liquors, darker spirits (brandy and whisky) triggered more symptoms than clear liquors (vodka). Overall, ethanol's role appears minimal, but given the varied ingredients and production methods of beer, wine, and liquor, some other component, such as polyphenols, is suggested. Higher levels of ethanol (0.1%) were evaluated over lower levels (0.02%) due to higher levels showing an effect during testing.

Polyphenols are a large family of naturally occurring organic compounds that are abundant in plants. They comprise multiple families of structurally diverse chemicals, including flavonoids, tannins, stilbenes, and lignans. Many of the plant‐based dyes, often found in the “skin” of the plant and to which their color is owed, derive from polyphenols such as anthocyanins. With respect to the grape, there is a much higher content of polyphenols in the skin. These polyphenols, in addition to resveratrol (a stilbenoid), have been extensively studied for their beneficial cardiovascular effects and their likely contribution to the observed “French paradox” of a healthy populace despite a high‐fat diet [17]. At times, beer has also been touted as “heart healthy” because of the polyphenols derived from the hops, which are often added for flavor and preservation. While distillates of grain fermentation would not be expected to contain any significant polyphenols, any subsequent aging and contact with wood barrels would provide some level of these compounds. Oak, for instance, provides hydrolyzable tannins and vanillic acid, a hydroxybenzoic polyphenol responsible for the vanilla and buttery notes attributed to oak aging. When taken in whole, this information would predict that the expected and observed concentrations of polyphenols within alcoholic beverages would be greatest for red wines and least for clear, nonaged distilled spirits. Levels within beer and white wine would vary based on their specific ingredients (grape varietal vs. grain), additives, and aging (steel vs. oak).

In this study, the effect on basophils of ethanol, RWE, resveratrol, catechin, and epigallocatechin (the latter two are both flavanols) was specifically evaluated. Resveratrol was selected for its purported health benefits and COX inhibition, while catechin was selected due to its high presence in red wine and beer [19]. EGC was also studied to explore why fermented beverages cause reactions, unlike nonalcoholic teas and other fruit/vegetable‐based drinks. We found that RWE and EGC dose‐dependently activated basophils, while ethanol did not. The RWE used was entirely polyphenolic (Table 1), suggesting that the effects of catechin may have reached significance with a greater sample size or relative concentration. Regardless, our data demonstrate that polyphenols activate granulocytes in AH patients, but not in controls. Though it is acknowledged that having been gathered from peripheral blood, these basophils may have different biomechanisms as compared to the nasal cellular milieu. Additional studies on peripheral tissue could be of benefit.

However, polyphenolic activation may not be the only cause of symptoms noted in patients with AH. Vally argued [6] that sulfites might also contribute, but this would only explain reactions to red and white wines. Furthermore, some individuals with a traditional flushing reaction are conflated with AH patients. The role of salicylates has long been debated in AERD. Samter stated that, “intolerance to acetylsalicylic acid is not an intolerance to salicylates” [3]. Vally suggested a potential role of salicylates, but the link between dietary salicylates and AERD is not established [16]. Studies from the 1960s showed sodium and phenyl salicylate could trigger urticaria, but AERD is a separate entity [20]. Additional studies have demonstrated the salicylate effects on patients with urticaria [18] and suggested the potential benefits of a low‐salicylate diet [21]. However, as stated, these were patients with NIUA, which is a separate entity from AERD/AIA. A 1995 study showed salicylates could trigger bronchoconstriction, but these patients were not diagnosed with AERD [22]. Two separate studies by Sommer et al. [23, 24] utilized a crossover study design to look at the effect of a low‐salicylate diet on AERD. In both their initial pilot and follow‐up multi‐institutional studies, they found a significant improvement in both symptom scores and endoscopic findings. The authors noted that a low‐salicylate diet is highly restrictive and requires the removal of alcoholic beverages in addition to fruits, vegetables, and spices, which have been noted to be high in salicylates. A major issue with this, however, is that given the level of dietary restriction, it's uncertain as to which specific chemical compound's removal may have resulted in symptomatic improvement, especially considering that all of these foods are also high in polyphenolic compounds.

Another potential issue of this study is whether the polyphenols tested apply to all alcoholic beverages. Further studies are needed to examine compounds from wooden barrels, like vanillic acid or other lignin derivatives. In vivo challenge studies with specific constituents should also be performed to confirm AH subjects and pair this with serological or other metabolic studies. Additionally, it remains unclear how these polyphenols may be activating the granulocytes and whether this is a direct process mediated through a cell surface receptor or if it could result through an intermediary such as granulocyte‐bound platelets, which are notable in these disease states [25].

5. Conclusions

Polyphenolic compounds can trigger the activation and degranulation of eosinophils and basophils, and this may explain the sensitivity to alcoholic beverages seen in patients with AERD and CRSwNP. Additional work is needed to clarify the exact mechanism through which this effect is mediated.

Conflicts of Interest

The authors declare no conflicts of interest.

Payne S. C., Eschenbacher W., Stepp R., and Borish L., “Polyphenolic Activation of Basophils Explains Alcohol Hypersensitivity in AERD ,” The Laryngoscope 136, no. 3 (2026): 1126–1133, 10.1002/lary.70183.