Your Patient is ‘Drunk’ but Didn't Drink Alcohol

Figure: Ethanol level, intoxication, auto-brewery syndrome, serum ethanol level, urinary tract infections, antibiotics, carbohydrate-fermenting microbiota, gastrointestinal abnormalities, strictures, short bowel syndrome, Crohn's disease, aldehyde dehydrogenase, liver insufficiency, cirrhosisFigure‘Her gut was producing alcohol. Doctors didn't believe her.” —Headline on CNN.com, June 3, 2024 (https://tinyurl.com/33ua55tx) This headline immediately caught my eye when it showed up in my Google feed. Not only was I as a medical toxicologist interested in all things alcohol, but that morning I had led a journal club on the topic of auto-brewery syndrome (ABS) for our toxicology service. It was almost as if Google knew more about me and what I would be interested in than I knew myself. Of course, it did. That's its business model. Auto-Brewery Syndrome in a 50-year-old Woman Zewude RT, et al. CMAJ 2024;196(21):E724 https://tinyurl.com/mpt8mw2t This patient was referred to a gastroenterology clinic after having been seen in the emergency department seven times over several years for ethanol intoxication, despite her repeatedly saying that she did not drink alcohol. Her serum alcohol level was as high as 180 mg/dL—almost twice the legal limit for presumed intoxication in many areas of the United States and Canada—during the first six presentations. (A serum ethanol level of 180 mg/dL is equivalent to a whole blood alcohol level of about 147 mg/dL.) The patient reported that she had had multiple episodes in which she felt lethargic and fell asleep unexpectedly, even while doing everyday tasks such as cooking or dressing. She had slurred speech and the odor of alcohol on her breath during emergency department visits, often for falls occurring because of excessive somnolence. She was invariably discharged with a diagnosis of alcohol intoxication. Various psychiatrists and addiction specialists who evaluated her were concerned that she was in denial about her seemingly obvious alcoholism. Her history revealed five years of frequent urinary tract infections treated with various antibiotics. Her serum alcohol level was 286 mg/dL during her seventh emergency department presentation, and the emergency physician raised the possibility that she had ABS. Diagnostic tests were performed, and a treatment plan was formulated. Carbohydrate-fermenting Microbiota ABS is rare. I have never seen a case nor has anyone I know. A systematic review identified only 20 patients with ABS in the medical literature as of September 2020. (United European Gastroenterol J. 2021;9[3]:332; https://tinyurl.com/mr3nh66v.) Many emergency physicians are unaware of the diagnosis or doubtful that it's really a thing. But there are now enough well-documented reports to prove that ABS exists. My view is that it should always be considered in the differential of a patient who shows up with a significant alcohol level but says he has no recent drinking. ABS is treatable, and making the diagnosis can radically improve a patient's life. ABS is caused by some combination of increased endogenous production of alcohol and decreased elimination. Increased production occurs when gut microbiota—bacteria or fungi—produce ethanol by fermenting carbohydrates. This happens all of the time, and most people will normally have low, virtually indetectable ethanol levels of 1 mg/dL or less. In fact, alcohol dehydrogenase may have evolved to eliminate these minimal levels constantly produced by gut organisms. But carbohydrate-fermenting microbiota can proliferate under certain circumstances, greatly increasing the amount of ethanol produced in the gut. Previous antibiotic treatment can allow organisms that ferment alcohol to proliferate. These include fungi such as Saccharomyces cerevisiae (brewer's yeast) and various Candida species, as well as bacteria such as Klebsiella pneumoniae and Escherichia coli. Abnormalities of the gastrointestinal tract can also be risk factors for ABS. These include strictures, short bowel syndrome, and Crohn's disease. Some cases of ABS will have no identifiable risk factors. Impaired metabolism of alcohol can also contribute to ABS. Some people in Asia, especially Japan, have a deficiency of the enzyme aldehyde dehydrogenase, impairing the conversion of aldehyde to acetate in the pathway of ethanol metabolism. That is why some people of Asian heritage have reduced tolerance for alcohol and experience a flushing reaction when they consume even a small amount. These patients can more readily develop ABS. Liver insufficiency in conditions such as cirrhosis can also contribute. Candida in GU Tract Urinary auto-brewery syndrome can also be caused by Candida infections in the genitourinary tract. (Ann Intern Med. 2020;172[10]:702.) Absorption of ethanol from the bladder may be less marked than absorption from the GI tract, but the bladder circulation does not drain into the portal system, so there is no first-pass metabolism. Diagnosis of ABS involves stool culture and endoscopic biopsy looking for causative organisms. Then the patient can be given an oral glucose challenge followed by serial alcohol levels. The patient must be monitored carefully during this test to eliminate the possibility of surreptitious alcohol ingestion. I could not find any standardization of the test regarding the glucose dose, the time course for the serial levels, or exactly which increase in serum or breath alcohol levels would qualify as a positive test. Treatment options include antifungal or antibiotic medications, a low-carbohydrate diet, and probiotics. One patient was successfully treated with a fecal transplant in one case report after these initial interventions failed. (Ann Intern Med. 2020;173[10]:855.) The 50-year-old patient described at the start of this article was treated empirically with fluconazole, a low-carb diet, and probiotics. Her symptoms resolved, and a subsequent glucose challenge was negative. Her culture never grew any suspicious organisms, but the authors noted that she received a course of fluconazole before culture specimens were obtained. Update: My past two columns covered different cannabinoid substances found in products available over the counter in smoke shops, gas stations, and other stores. (http://tinyurl.com/EMN-Gussow.) The Food & Drug Administration has since issued a warning about serious adverse effects including one possible death associated with the consumption of Diamond Shruumz edibles. (July 16, 2024; https://tinyurl.com/d3bsmx8m.) Our group has seen a case of prolonged psychotic reaction after exposure to an edible labelled as containing delta-8 THC. A main problem is that this market is largely unregulated about what the products contain and at what doses. What you see is not necessarily what you get. DR. GUSSOW is a voluntary attending physician at the John H. Stroger Hospital of Cook County in Chicago, an assistant professor of emergency medicine at Rush Medical College, a consultant to the Illinois Poison Center, and a lecturer in emergency medicine at the University of Illinois Medical Center in Chicago. Follow him on X @poisonreview, and read his past columns at http://tinyurl.com/EMN-Gussow. Share this article on X and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

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