The Case of the Drunken Teetotaler

Auto-brewery syndrome is a rare multifactorial disease in which endogenous alcohol production occurs due to an overpopulation of fermentable microorganisms (especially Saccharomyces cerevisiae and Candida species but also bacteria like Klebsiella pneumoniae).

Even in the healthy population, there is a low level of endogenous fermentation that is not enough to cause alcohol intoxication. The genesis of auto-brewery syndrome involves a carbohydrate-rich diet and in part a genetic predisposition, such as inefficient alcohol metabolism. In addition, there are associations with diabetes mellitus, liver diseases, gastrointestinal motility disorders, and chronic inflammatory bowel diseases.

Abstinence From Alcohol 

A 5src-year-old patient from Toronto, presented repeatedly to the emergency department over 2 years with alcohol intoxication despite credible denial of alcohol consumption. For several years, she had not been drinking alcohol for religious reasons, a fact confirmed by her husband and son. In addition, the patient had recurring episodes of somnolence and situations where she would fall asleep during everyday activities like cooking, leading to frequent falls.

Before these episodes began, the patient had repeated urinary tract infections over about 5 years, which were treated with antibiotics (ciprofloxacin and nitrofurantoin). Due to reflux disease, she also took dexlansoprazole.

Emergency Department Visits 

In the emergency department, the patient presented with slurred speech and alcoholic breath. An alcohol level of up to 62 mmol/L in the blood (normal level, <2 mmol/L) was measured, with normal liver function tests. A CT scan was normal, and existing alcohol abuse was ruled out by multiple psychiatrists.

It is noteworthy that during one of her many emergency department visits, the patient was involuntarily admitted to psychiatry due to concerns of self-harm by the attending physician when the patient tried to leave before a psychiatric evaluation.

The lethargy and somnolence, accompanied by loss of appetite, persisted for 1-2 weeks, after which the patient was symptom-free until a new episode occurred after 1-2 months.

Low-Carb Diet 

It was only during the seventh emergency department visit that the attending physician considered auto-brewery syndrome, prescribing oral fluconazole and referring the patient to a gastroenterologist. The gastroenterologist recommended adhering to a low-carb diet. After 1 month of fluconazole and 4 months of the diet, the patient was symptom-free, so she resumed eating carbohydrates. This led to a new episode of the known symptoms. The therapy was repeated a second time, also successfully, and the patient was referred to infectious disease specialists. After 6 weeks without symptoms, fluconazole was discontinued due to medication-related elevated liver enzymes.

The infectious disease specialists sampled gastrointestinal secretions via esophagogastroduodenoscopy and colonoscopy. The subsequent cultures showed no microbial growth, as expected after previous fluconazole treatment. Furthermore, supplementation with probiotics (Lactobacillus acidophilus) was initiated, and the patient was advised to avoid broad-spectrum antibiotics.

The patient remained symptom-free for 6 months, prompting an oral glucose tolerance test (with 15src mg of glucose) with ethanol concentration measurements at src.5, 1, 2, 3, 4, 5, 24, and 48 hours. The ethanol concentrations remained within the normal range throughout. Consequently, the patient was able to reintroduce a carbohydrate-rich diet gradually.

Early Diagnosis Crucial 

In the patient, the intake of dexlansoprazole and repeated antibiotic use likely led to a change in the microbial flora.

To avoid difficulties in identifying the responsible microbial species (as observed in the case of the patient), microbial diagnostics should be performed before empirically initiating antifungal therapy.

Interdisciplinary care involving a low-carb diet and antifungal therapy, either empirically with fluconazole for 3 weeks or based on microbiological findings, is the preferred therapeutic approach. Successful treatments with fecal transplants have also been described.

Early diagnosis of auto-brewery syndrome is important, as patients are significantly impaired in social participation in daily life and work due to fatigue. Legal consequences, such as driving under the influence of alcohol, and health effects like liver cirrhosis should also be considered.

The case demonstrates that when facing recurrent alcohol intoxications with specific risk factors like multiple antibiotic use, a carbohydrate-rich diet, certain comorbidities, and a credible denial of alcohol consumption, auto-brewery syndrome should be considered to enable early diagnosis and treatment.

This story was translated from Univadis Germany using several edi