Drunk Without Drinking: A Case of Auto-Brewery Syndrome

Auto-Brewery Syndrome and General Anesthesia: A Case Report

Auto-brewery syndrome (ABS) is a rare condition in which ethanol is endogenously fermented by fungi in the gut following a carbohydrate-rich meal, resulting in intoxication. We present a case of a patient with ABS successfully undergoing general anesthesia for symptomatic wisdom tooth extraction. During previous anesthetics, the patient had experienced postoperative nausea and vomiting (PONV) and awareness under anesthesia. Patients with ABS can be optimized for anesthesia by assessing hepatic function, avoiding perioperative oral carbohydrates, increasing anesthetic depth, multimodal PONV prophylaxis, and avoidance of broad-spectrum antibiotics.

Three Klebsiella species as potential pathobionts generating endogenous ethanol in a clinical cohort of patients with auto-brewery syndrome: a case control study

BACKGROUND

Patients with auto-brewery syndrome (ABS) become inebriated after the ingestion of an alcohol-free, high-carbohydrate diet. Our previous work has shown that high-alcohol-producing (HiAlc) Klebsiella pneumoniae can generate excessive endogenous ethanol and cause non-alcoholic fatty liver disease (NAFLD). Therefore, it is reasonable to speculate that such bacteria might play an important role in the pathogenesis of ABS.

METHODS

The characteristics and metabolites of the intestinal flora from a clinical cohort of patients with ABS were analysed during different stages of disease and compared to a group of healthy controls. An in vitro culture system of relevant samples was used for screening drug sensitivity and ABS-inducing factors. Rabbit intestinal and murine models were established to verify if the isolated strains could induce ABS in vivo.

FINDINGS

We observed intestinal dysbiosis with decreased abundance of Firmicutes and increased of Proteobacteria in patients with ABS compared with healthy controls. The abundance of the genus Klebsiella in Enterobacteriaceae was strongly associated with fluctuations of patient's blood alcohol concentration. We isolated three species of HiAlc Klebsiella from ABS patients, which were able to induce ABS in mice. Monosaccharide content was identified as a potential food-related inducing factor for alcohol production. Treatments with antibiotics, a complex probiotic preparation and a low-carbohydrate diet not only alleviated ABS, but also erased ABS relapse during the follow-up observation of one of the patients.

INTERPRETATION

Excessive endogenous alcohol produced by HiAlc Klebsiella species was an underlying cause of bacterial ABS. Combined prescription of appropriate antibiotics, complex probiotic preparation and a controlled diet could be sufficient for treatment of bacteria-caused ABS.

FUNDING

The funders are listed in the acknowledgement.

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

OBJECTIVES

Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome.

CASE PRESENTATION

This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1-2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome.

CONCLUSIONS

Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

The Auto-Brewery Syndrome: A Perfect Metabolic "Storm" with Clinical and Forensic Implications

Auto-brewery syndrome (ABS) is a rare, unstudied, unknown, and underreported phenomenon in modern medicine. Patients with this syndrome become inebriated and may suffer the medical and social implications of alcoholism, including arrest for inebriated driving. The pathophysiology of ABS is reportedly due to a fungal type dysbiosis of the gut that ferments some carbohydrates into ethanol and may mimic a food allergy or intolerance. This syndrome should be considered in patients with chronic obstruction or hypomotility presenting with elevated breath and blood alcohol concentrations, especially after a high carbohydrate intake. A glucose challenge test should be performed as the confirmatory test. Treatment typically includes antifungal drugs combined with changes in lifestyle and nutrition. Additional studies are particularly needed on the human microbiome to shed light on how imbalances of commensal bacteria in the gut allow yeast to colonize on a pathological level.

Case Report: Diabetic urinary auto-brewery and review of literature

Background: Although candiduria is an expected encounter and should not be surprising in uncontrolled diabetes with glucose-enriched urine, urinary auto-brewery is rarely thought of by diabetologists. Moreover, endogenous ethanol production in humans from gut microbiome, urinary tract fungi and bacteria, and intermediary metabolism, has been reported for a long time, particularly in diabetics. 

Case description: To alert physicians to the overlooked implication of endogenously produced ethanol both as a biomarker for poor control of diabetes and as a complicating factor, we report this case of an elderly male smoker alcohol-abstinent insulin-dependent Type 2 diabetic patient. Because of circumstantial treatment and incompliance for one week, he developed endogenously produced alcohol intoxication. We proposed candidal urinary auto-brewery evidence sourced from the case history, urinalysis, and culture/identification tests - without excluding other sources. Fortunately, his diet and glycemic control were fairly controlled and, liver and kidney functions were almost normal. Amphotericin B I/V for five days, insulin, and a fluid therapy regimen greatly improved the case and cleared both the candiduria and ethanol from the urine and blood and the patient regained his base-line normal life.  

Conclusion: Symptoms of alcohol intoxication should be expected in patients with uncontrolled diabetes that most often correlates with candiduria and/or constipation. These symptoms can be exaggerated in those already suffering a degree of dementia and/or comorbid psychiatric/neurologic affections. Direct wet mount examination of urine under phase contrast microscopy would show the budding yeast cells.  Appropriate antifungal, insulin and fluid therapies regained the base-line norms.

Gut fermentation syndrome: A systematic review of case reports

BACKGROUND

The gut fermentation syndrome (GFS), also known as the endogenous alcohol fermentation syndrome or auto brewery syndrome, is a rare and underdiagnosed medical condition where consumed carbohydrates are converted to alcohol by the microbiota in the gastrointestinal or urinary tract. The symptoms of GFS can have severe impact on patients' wellbeing and can have social and legal consequences. Unfortunately, not much is reported about GFS. The aim of this systematic review was to assess the evidence for GFS, causal micro-organisms, diagnostics, and possible treatments.

METHODS

A protocol was developed prior to initiation of the systematic review (PROSPERO 207182). We performed a literature search for clinical studies on 1 September 2020 using PubMed and Embase. We included all clinical studies, including case reports that described the GFS.

RESULTS

In total, 17 case reports were included, consisting of 20 patients diagnosed with GFS. The species that caused the GFS included Klebsiella pneumoniae, Candida albicans, C. glabrata, Saccharomyces cerevisiae, C. intermedia, C. parapsilosis, and C. kefyr.

CONCLUSIONS

GFS is a rare but underdiagnosed disease in daily practice. The disease is mostly reported by Saccharomyces and Candida genera, and some cases were previously treated with antibiotics. Studies in Nonalcoholic Fatty Liver disease suggest a bacterial origin of endogenous alcohol-production, which might also be causal micro-organisms in GFS. Current treatments for GFS include antibiotics, antifungal medication, low carbohydrate diet, and probiotics. There might be a potential role of fecal microbiota transplant in the treatment of GFS.

Auto-Brewery Syndrome: A Clinical Dilemma

Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a very rare disorder. It is characterized by the endogenous production of alcohol. It typically presents with the signs of alcohol intoxication, such as staggering gait, slurred speech, gastrointestinal distress, and state of confusion. Due to the nonspecific symptoms, it is necessary to rule out other etiologies before reaching a diagnosis of ABS. The confirmatory test for this syndrome is the raised levels of blood or breath ethanol after a glucose challenge test. The management includes the use of antifungal drugs and avoidance of a carbohydrate-rich diet. In this review, we summarize the etiology, clinical presentation, diagnostic tests, management, and medicolegal aspects of ABS.