Before contracting COVID in March 2020, Rebecca Stein could enjoy a handful of alcoholic drinks a week. She assumed nothing had changed since her mild infection, so when she saw her husband holding a tempting glass of whiskey one evening, she took a small sip.
Within a minute, severe chest pain set in and Stein, 30, became so drunk she felt like she’d had several drinks at once. The next day was worse, but it wasn’t the usual hangover: she had an irregular heartbeat, chest pain, cough, sore throat, headache and stuffy nose. It was “basically a relapse of COVID,” said Stein, who is also dealing with others long covid symptoms including shortness of breath, regular fevers, body aches and fatigue.
“When it first happened, I hadn’t connected the dots. I would wake up and get tested for COVID because I had all the symptoms of COVID and when I drink, my heart rate goes really high overnight,” Stein said. “My body seems to pick up on being poisoned pretty quickly.”
Almost three years later, Stein is still unable to drink alcohol of any kind. And she’s not alone.
Alcohol intolerance after COVID hasn’t been studied yet, so no one knows how common it really is, but interviews with doctors, researchers and people who can no longer drink alcohol suggest it’s another mystery symptom that can is a side effect of the viral infection.
The long COVID aka post-covid conditions, occurs when health problems persist for weeks, months, or even years after a coronavirus infection. It was recognized by the Americans with Disabilities Act in 2021, and approximately 30 percent of adults may experience at least one symptom of COVID that lasts three months or more, according to research.
Dr. Stuart Malcolm, an internal medicine physician who only treats patients with long-term COVID at RTHM clinic, said many people with long-term COVID have given up alcohol entirely “because it doesn’t seem to universally make people feel good.” But he estimates that about 5% to 10% of his patients (or about 10 to 20 people in his practice) experience this intolerance as they continue to experiment with alcohol consumption.
A neurologist with long COVID in Louisiana also wrote about his experience with it in a March 2021 blog post, and a Reddit thread since last February has revealed more people dealing with the same problem.
Alcohol intolerance can occur even in those who have not had long-term COVID, may disappear or become milder over time, and may be triggered by certain types of alcohol but not others. Although uncomfortable, the inability to drink alcohol is not the most devastating of symptoms compared to the more serious effects.
However, experts, especially those who study or treat people with ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) — a complex illness that shares many similarities with long-term COVID — you’re not too shocked to hear about this event.
Alcohol intolerance is actually a a key diagnostic feature of ME/CFS. Studies have found that it occurs anywhere between 65% to 80% of people with the disease.
“It doesn’t surprise me at all because we now know that there are all kinds of underlying biological abnormalities in people with ME/CFS that involve the immune system, energy metabolism, the brain, the autonomic nervous system and the gut microbiome, most of which are now occurring in people with long COVID,” said Dr. Anthony Komarov, a professor of medicine at Harvard Medical School who has studied ME/CFS for 35 years. “But what exactly are the abnormalities that lead to alcohol intolerance, we still don’t know.”
What is alcohol intolerance?
Alcohol intolerance usually an inherited metabolic disorder that prevents people from processing alcohol the way other people do; a genetic mutation makes a specific enzyme or protein less effective at turning alcohol into a non-toxic substance, causing toxins to build up in the blood.
As a result, people’s faces, necks, and chests become flushed—warm and pink or red in color—almost immediately after drinking alcohol. They may also experience stuffy nose, nausea, vomiting, rapid heart rate, low blood pressure, headache, diarrhea and worsening asthma.
The condition does not go away, but people can manage it by avoiding any type of alcohol. People of Asian descent are more likely to have the genetic mutation, so the disease is more common in them than in other racial groups.
Although it may seem like it, alcohol intolerance does not make people get drunk faster or raise blood alcohol levels. The condition is also different from an alcohol allergy, which is an immune response to a chemical, grain, or preservative in alcohol that can cause rashes, itching, swelling, and stomach cramps.
Both conditions can cause nausea, but an alcohol allergy is usually more painful and can be life-threatening if left untreated.
However, when associated with prolonged COVID or another chronic condition, alcohol intolerance likely damages the body through a different chemical mechanism that does not involve an inherited genetic mutation or allergy, Komarov said.
It’s also possible that the coronavirus directly affects the enzymes responsible for processing alcohol, said Dr. Vikrant Rachakonda, a hepatologist, gastroenterologist and professor of medicine at UC Davis Health.
But that remains to be seen.
Why do some people have alcohol intolerance after COVID?
There are several plausible explanations behind alcohol intolerance after COVID, but it has not been thoroughly studied. Most speculation is based on what scientists have learned about the long-term effects of COVID on the body and research on ME/CFS.
Given how complex COVID is, it’s unlikely that just one of these theories can fully explain what’s going on. Here are three of the main ones according to experts.
Liver damage
The liver processes everything we consume, including alcohol, so when the organ is injured or weakened in some way, it becomes vulnerable to further injury when exposed to toxins, such as alcohol, Komarov said.
COVID can damage the liver in more ways than one, and some experts, like Malcolm, the longtime COVID doctor, suspect the disease causes “a little more damage to the liver than we thought that wasn’t evident in standard lab tests.”
That’s all to say that a damaged liver—or undiagnosed liver disease, which Rachakonda says is very common because most cases are asymptomatic—probably won’t process alcohol properly. People who are alcohol intolerant after COVID may have suffered acute liver damage from their infection or have undiagnosed liver disease.
Rachakonda said it’s not unreasonable to ask for a blood test if you have an alcohol intolerance. Checking liver enzymes as well as kidney function and electrolytes can help rule out other causes.
Mast cell activation
Mast cells are a type of immune cell that cause allergic reactions when they detect an allergen such as peanut proteins. They do this by releasing a chemical called histamine, which works to get rid of the allergen by making you itch, sneeze, gag, wheeze, etc. (Komaroff actually suspects that alcohol intolerance after COVID may even be a “type of allergy” reaction.)
Studies show that prolonged COVID exacerbates this process by activating mast cells, encouraging them to release additional histamine into the body. (ME/CFS also does this.) It can mimic the symptoms of mast cell activation syndrome, a condition that causes people to have repeated episodes of anaphylaxis-like symptoms, such as hives, low blood pressure, severe diarrhea, and difficulty breathing. (Anaphylaxis is a potentially life-threatening allergic reaction.)
To make matters worse, alcohol not only contains histamine—it’s a byproduct of the fermentation and brewing process—but it also prompts mast cells to release more of it and then blocks an enzyme called the DAO enzyme from breaking down histamine.
“It’s kind of a triple whammy,” Malcolm said. All that extra histamine may explain why some people feel terrible after drinking alcohol post-COVID.
This theory may also help explain why alcohol intolerance may disappear or become milder over time. As your body clears the virus and begins to recover from the injuries it has caused, there is less chaos to trigger your mast cells to release extra histamine.
That could happen to 26-year-old Serena Quinlan. When she contracted COVID in February 2021, she experienced a loss of taste and smell for several weeks, which included a strange aversion to foods like onions and guacamole. However, after a few nights out with friends and solo wine dinners at home involving just a few drinks, Quinlan noticed her body was acting like she was at least eight, she told BuzzFeed News.
“The rest of the spring and summer I just really, really struggled if I had a drink. I would wake up so hungover, with a terrible headache and super tired,” said Quinlan, a law student in Tennessee. “It was so weird.”
Her boyfriend, who initially infected her with COVID, experienced the same symptoms: “She texted me herself and asked me if I die every time I drink alcohol,” Quinlan said.
After three months, her alcohol intolerance disappeared completely.
Blood flow problems
Many long-term COVID patients (along with ME/CFS patients) experience problems with their autonomic nervous system, which plays a critical role in how blood vessels constrict and dilate, but researchers still don’t fully understand why.
When someone has long-term COVID or ME/CFS, their blood vessels cannot respond properly to signals from the brain to constrict or relax. This is why many people with long COVID feel dizzy or even pass out after standing up because their blood vessels don’t constrict enough, causing their blood pressure to drop. This is a hallmark symptom of POTS…
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