Recurrent Alcohol Intoxication Despite Abstinence: A Case of Auto-Brewery Syndrome

Core Concepts

Auto-brewery syndrome is a rare condition where endogenous alcohol production leads to recurrent alcohol intoxication, even in individuals who abstain from alcohol consumption.

Abstract

The content describes the case of a 50-year-old patient from Toronto who presented repeatedly to the emergency department with alcohol intoxication despite credible denial of alcohol consumption. The patient had not been drinking alcohol for religious reasons, as confirmed by her family.

The patient had a history of recurrent urinary tract infections, reflux disease, and had taken antibiotics and proton-pump inhibitors. In the emergency department, the patient presented with slurred speech, alcoholic breath, and blood alcohol levels up to 62 mmol/L (normal < 2 mmol/L), despite normal liver function tests.

After multiple visits and psychiatric evaluations, the attending physician finally considered auto-brewery syndrome. The patient was prescribed oral fluconazole and advised to follow a low-carb diet, which led to resolution of symptoms. However, resuming a carbohydrate-rich diet triggered a recurrence of the episodes.

The case highlights the importance of early diagnosis of auto-brewery syndrome, as it can significantly impair a patient's social and work life. Interdisciplinary care involving a low-carb diet and antifungal therapy is the preferred therapeutic approach. Microbial diagnostics should be performed before initiating empirical antifungal therapy to identify the responsible microbial species.

Stats

Blood alcohol level up to 62 mmol/L (normal < 2 mmol/L)
Normal liver function tests

Quotes

"Even in the healthy population, there is a low level of endogenous fermentation that is not enough to cause alcohol intoxication."
"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."

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Deeper Inquiries

What are the potential long-term health consequences of untreated auto-brewery syndrome?

Untreated auto-brewery syndrome can lead to various long-term health consequences, primarily due to chronic alcohol exposure. Prolonged alcohol production in the body can result in liver damage, including liver cirrhosis, fatty liver disease, and hepatitis. These conditions can progress to more severe complications such as liver failure and an increased risk of hepatocellular carcinoma. Additionally, chronic alcohol exposure can impact other organs and systems, leading to cardiovascular issues, neurological disorders, gastrointestinal problems, and metabolic disturbances. Mental health issues like depression and anxiety may also arise due to the social and psychological implications of the condition.

How can the diagnostic process for auto-brewery syndrome be improved to avoid misdiagnosis and delayed treatment?

Improving the diagnostic process for auto-brewery syndrome involves a comprehensive approach that considers the patient's medical history, symptoms, and risk factors. Healthcare providers should be aware of the condition and its atypical presentation to prevent misdiagnosis. Utilizing advanced diagnostic tools such as microbial diagnostics before initiating antifungal therapy can help identify the responsible microbial species accurately. Collaboration between different medical specialties, including gastroenterology, infectious diseases, and psychiatry, can facilitate a more holistic evaluation of the patient. Educating healthcare professionals about the unique features of auto-brewery syndrome and promoting awareness among the general population can also aid in early detection and timely treatment.

What role do gut microbiome alterations play in the development of auto-brewery syndrome, and how can this knowledge be leveraged for more effective treatment strategies?

Gut microbiome alterations play a crucial role in the development of auto-brewery syndrome by promoting the overgrowth of fermentable microorganisms like Saccharomyces cerevisiae and Candida species. Factors such as antibiotic use, proton pump inhibitors, and dietary habits can disrupt the balance of gut flora, creating an environment conducive to alcohol production. Understanding these microbial changes can help in designing more effective treatment strategies for auto-brewery syndrome. Therapeutic approaches targeting the gut microbiome, such as probiotics and fecal transplants, can help restore microbial balance and reduce alcohol production. Implementing personalized dietary interventions, like a low-carb diet, can further support the normalization of gut flora and prevent alcohol fermentation. By leveraging knowledge of gut microbiome alterations, healthcare providers can tailor treatment plans to address the underlying microbial dysbiosis and improve patient outcomes.