2551 A Case of Auto-Brewery Syndrome: Probably an Under-Diagnosed Medical Condition

Abstract

INTRODUCTION: Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a rarely diagnosed medical condition in which the ingestion of carbohydrates results in endogenous alcohol production. The patient in this case report had fungal yeast forms in the upper small bowel and cecum, which likely fermented carbohydrates to alcohol. Treatment with antifungal agents allowed subsequent ingestion of carbohydrates without symptoms. He had been exposed to a prolonged course of antibiotics before this occurred. We postulate that the antibiotic altered his gut microbiome, allowing fungal growth. CASE DESCRIPTION/METHODS: A healthy 46-year-old male who complained of memory loss, mental changes, and episodes of depression for over three years after antibiotic therapy (cephalexin) for a traumatic thumb injury. He was given a carbohydrate meal and blood alcohol level became elevated to 57 mg/dL without any exogenous alcohol while under observation. Saccharomyces cerevisiae (brewer's yeast) and Saccharomyces boulardii were detected in his stool. To investigate further, an upper and lower endoscopy were performed. Fungal cultures from cecal secretions grew Candida Albicans and Candida Parapsilosis. He was started on a carbohydrate free diet and intravenous micafungin therapy for six weeks after which secretions from a repeat endoscopy showed absence of fungal growth. He was also started on a probiotic to competitively inhibit fungal growth in his gut. A repeat carbohydrate challenge test was negative for endogenous alcohol production now. Approximately 2 years later, he remains asymptomatic and has resumed his previous lifestyle, including eating a normal diet. DISCUSSION: A large Middle Eastern study involving 1400 subjects who were teetotalers detected very small endogenously produced alcohol levels using gas chromatography and mass spectrometry. Saccharomyces cerevisiae which can convert carbohydrates to endogenous alcohol, was detected in our patient's stool. This fungus uses acetate for anaerobic alcohol fermentation. It should be noted that the earliest symptoms of ABS may be mood changes, delirium, and brain fog rather than the medical manifestation of alcohol inebriation. A multidisciplinary approach with early psychiatrist involvement is suggested. Any patient denying alcohol ingestion but who has elevated blood alcohol levels or positive breathalyzer results should be investigated for ABS. This could be a treatable condition with dietary modifications, appropriate antifungal therapy and probiotic use.