Life and science are full of surprises and incredible things. I came to an article in Medscape and BMJ Gastroenterology written by Dr. Fahad Malik et al. from New York about an interesting case report I would like to share. Does this information fit like a glove before New Year's Party? Who knows...?
A patient was treated years before with oral antibiotics for one week because of a complicated traumatic finger injury. One week after, the patient had personality changes with aggressiveness. He was a different person and started medication prescribed by a psychiatrist. Nothing changed. One day he was arrested for drunken driving. A blood test revealed 200 mg/dl (2,0 g/L) of alcohol. However, he denied alcohol ingestion from the very beginning. No one in the hospital believed him. How could he be drunk without drinking alcohol? Well, it is possible.
Auto-Brewery Syndrome (ABS), also called gut fermentation syndrome, can be responsible for these cases. Patients suffering from ABS have an endogenous production of alcohol following carbohydrates ingestion. Fungal yeast in the bowel ferments carbohydrates to alcohol. What? Incredible.
Back to the case reported, the patient's stools were positive for Saccharomyces cerevisiae (brewer's yeast). For diagnosis confirmation, he ingested a carbohydrate meal, and eight hours later his blood alcohol level was 57 mg/dl (0,57 g/L). Fermentation was happening inside his bowel and producing alcohol. He started antifungal agents and a carbohydrate-free diet. Some weeks later he relapsed and had intracranial bleeding from a falling. Once again, no one believed he was not ingesting alcoholic beverages because his blood alcohol was constantly ranging from 50-400 mg/dl (0,5-4,0 g/L).
At his time, he asked Dr. Malik's in New York to help him. Cultures from the stomach, upper small bowel, and cecum were positive for fungal (Candida species). He became asymptomatic after antifungal treatment. However, after eating pizza and drinking soda he relapsed again. Intravenous micafungin 150 mg a day for six weeks, along with a probiotic, was given. In the end, cultures were negative for fungal species, he is on a normal diet, free of symptoms, not taking any medication, but checking breath alcohol sporadically.
Previous reports of Auto-Brewery Syndrome came from Japan in 1970 and ten years later from the USA. Most of those studies report the ABS in immunocompromised patients, Crohn's disease, and short gut syndrome. The case presented by Dr. Malik et al. is the first ABS triggered by antibiotics. According to the authors, the usage of antibiotics altered the microbiome and allowed fungi to grow. Candida and Saccharomyces cerevisiae (found in the patient's gut) can convert carbohydrates to alcohol. S. cerevisiae is used in the fermentation process.
Doctors must consider ABS diagnosis in all patients with mood changes, brain fog, delirium, or signs of inebriation, who deny alcohol ingestion. As the authors state, ABS can make the patient suffer all negative implications from being drunk, including an arrest for drunken driving. Can you imagine how it would sound like a guy with a drunken speech telling a policeman: "I cannot be drunk because I only drunk orange juice."
Unfortunately, this is a not well-known condition, and there are no diagnostic criteria or treatment guidelines. Dr. Malik et al. advise a provocative carbohydrate challenging test (read the article to know more) plus alcohol blood analysis. It is important to test blood samples at 16h and 24h because sometimes fermentation can take up to 24 h or more. Secretions from the stomach, upper small bowel, and colon must be collected for bacteria and fungi cultures. The presence of fungi in the stomach and upper small bowel is probably pathological.
An increased ethanol level during the carbohydrate test confirms the Auto-Brewery Syndrome. Treatment includes antifungal agents, a carbohydrate-free diet, and periodic breath analysis. Probiotics yes, or no? Who knows…?
Doctors must suspect Auto-Brewery Syndrome (ABS) in all patients with an increased blood alcohol or positive breathalyzer who deny alcohol ingestion. This case report shows that ignorance was why everyone refused to believe in the patient's "innocence" from the very beginning. Everyone was very fast to conclude he was drunk and lying.
Must not forget that mood changes with aggressiveness can be the first presentation of ABS, even before clear signs of alcohol intoxication. Rare conditions do exist. Knowing them is crucial for making a correct diagnosis. As doctors, we must assume we do not know or fully understand many existing diseases. Exams are only a tool and not a verdict. Exams must be read and interpreted following a complete clinical history and full physical examination. In that setting, we must keep an open mind, have time to listen to the patient, and believe the unbelievable. Remember: the difference between fiction and reality is that the former must look like reality. Real-life will always surprise us.
Always keep in your mind:
Doubt is what makes me go further, not the certainty.
Link to Article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon