Rarely reported case of Auto-brewery syndrome

In the present case, the patient was an active, healthy, 46-year-old man (height, 6 feet 2 inches; weight, 230 lbs; body mass index, 30 kg/m2) with no significant medical or psychiatric history. He sought the help of doctors for the confirmation and treatment of ABS. He was not taking any medications, including herbal or over-the-counter drugs.

He reported that in 2011 after the completion of his antibiotic therapy for a thumb injury, he started experiencing “very uncharacteristic” personality changes, along with episodes of depression and memory loss. He was initially evaluated by his primary care physician (PCP) before being referred to a psychiatrist who treated him with lorazepam and fluoxetine.

One morning, he was arrested for presumed driving while intoxicated (DWI). He refused a breathalyser analysis and was hospitalised. His initial blood alcohol level was 200 mg/dL. The hospital personnel and police refused to believe him when he repeatedly denied alcohol ingestion. He recovered fully and was discharged.

After hearing about a similar successfully treated case by a physician in Ohio, his aunt purchased a breathalyser to record his breath alcohol levels and persuaded him to visit Ohio for the treatment, where basic laboratory testing (complete blood count, comprehensive metabolic panel, immunology panel, and urinalysis) were all normal. A comprehensive stool analysis was negative for Giardia and Cryptosporidium. The patient’s lactoferrin, calprotectin, and lysozyme levels and stool malabsorption studies were also normal. Saccharomyces cerevisiae (brewer’s yeast) and S. boulardii were detected in his stool addition to his normal stool bacterial flora. On antifungal sensitivity testing, these Saccharomyces strains were found to be sensitive to azoles and nystatin.

To confirm the diagnosis of Auto-brewery syndrome, the patient was given a carbohydrate meal, and his blood alcohol levels were monitored under observation. After 8 hours, his blood alcohol level was elevated to 57 mg/dL. He was then treated for the Saccharomyces fungi found in his stool with oral fluconazole 150 mg per day for 14 days. In the absence of improvement, on day 10, this was changed to nystatin 500 000 IU three times a day for another 10 days. His symptoms improved, and he was discharged on a strict carbohydrate-free diet along with special supplements given by his Ohio physician, but no further antifungal therapy was prescribed.

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. The authors postulated that the antibiotic altered his gut microbiome, allowing fungal growth.

The aim of this case report was confirmation and treatment of Auto-brewery syndrome (ABS) using a standardised carbohydrate challenge test followed by upper and lower endoscopy to obtain intestinal secretions to detect fungal growth. These fungi were speciated and antifungal sensitivity performed. This allowed the use of appropriate therapy. The patient was kept on a carbohydrate-free diet during the initial 6-week period of therapy. A single-strain probiotic for competitive inhibition of fungal growth was given to the patient. This probiotic was later replaced by a multistrain bacterial probiotic hoping that the multiple bacteria would inhibit fungi better than a single-strain. The beneficial role of probiotics in this condition has not been studied. The patient was rechallenged for endogenous alcohol production prior to reintroducing carbohydrates in his diet

Auto-brewery syndrome should be considered as a possibility in any patient who shows alcohol toxicity, but denies drinking alcohol, doctors at Richmond University Medical Center in New York wrote as they described the unnamed man’s case in BMJ Open Gastroenterology.

For further reference log on to :

http://dx.doi.org/10.1136/bmjgast-2019-000325