Case Presentation:
A 25-year-old man was found unresponsive at his home and brought to the hospital for further evaluation. In the emergency department, his Glasgow coma scale was 6, for which he was intubated and started on mechanical ventilation. His past medical history was remarkable for diabetes mellitus type 2, for which he was on metformin. His vital signs were remarkable for respiratory rate of 25/minute and blood pressure of 91/47 mm Hg. Physical examination was limited as the patient was under sedation. On initial blood work, complete blood count was within normal limits and the comprehensive metabolic panel was remarkable for glucose of 173 mg/dl, and aspartate aminotransferase and alanine aminotransferase were elevated at 90 U/L and 271 U/L respectively. Patient’s serum alcohol level was 0.710 g/dL (normal-undetectable). We made a diagnosis of acute metabolic encephalopathy secondary to ethyl alcohol overdose. On day 2, the patient was weaned off of mechanical ventilation. On subsequent evaluation, he mentioned a three-month history of intermittent episodes of right side abdominal pain, headache, and dizziness. He strongly denied any history of alcohol intake and his family also confirmed that he was a teetotaler. A computed tomography (CT) scan of the abdomen showed findings consistent with fatty liver. His serum alcohol level slowly declined during hospitalization. Given the significant elevation of serum alcohol level and plausible denial of alcohol use, a diagnosis of gut fermentation syndrome was pursued. Esophagogastroduodenoscopy was done to obtain gastric and esophageal aspirates for fungal culture. A stool sample was also sent for fungal culture. Later, both these samples showed growth of Candida albicans. This supported the diagnosis of gut fermentation syndrome, for which patient received treatment with a 21-day course of fluconazole and nystatin. On regular outpatient follow-ups, his serum alcohol levels were unremarkable, and he remained asymptomatic.
Discussion:
Gut fermentation or Auto-Brewery syndrome is a rare disease that commonly affects immunocompromised patients. Previous case reports have suggested that the pathophysiology is related to overgrowth of certain species of Candida, including C. Albicans, C. Krusei, C. Glabrata, and Saccharomyces cerevisiae. These fungi metabolize carbohydrate to ethyl alcohol in the gut and lead to elevated serum levels of alcohol. Patients present with signs and symptoms of alcohol intoxication and a negative history of alcohol intake. Fungal cultures of stool and the gastric aspirate specimen can help in establishing the diagnosis. In some patients, carbohydrate challenge with certain specific foods may reproduce symptoms, and serum alcohol level may rise, suggesting this diagnosis.
Since this disease is very rare, physicians require a high level of suspicion and awareness to diagnose this entity. If undiagnosed, the auto-brewery syndrome can pose negative personal, professional, emotional and sometimes, legal implications for patients and their families.
Conclusions:
Auto-Brewery syndrome is a possible diagnosis in a patient with a negative history of alcohol consumption and elevated serum ethyl alcohol level. Stool and gastric fungal cultures should be obtained to assess for the growth of Candida or Saccharomyces cerevisiae. A short course of anti-fungal medications can prevent recurrence.