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His breath smelled of alcohol. She was dizzy, disoriented and weak, so much so that one day she passed out and hit her head on the kitchen counter while making lunch for her school-age children.
Yet not a drop of alcohol had spilled on her lips, a fact the 50-year-old Torontonian and her husband told doctors for two years before anyone actually believed her.
“She visited her family doctor over and over again and went to the emergency room seven times in two years,” said Dr. Rahel Zewude, an infectious disease specialist at the University of Toronto.
Doctors found that the woman’s alcohol level could vary between 30 millimoles per liter and 62 millimoles per liter – anything less than 2 millimoles per liter is normal, Zewude said.
Alcohol levels of up to 62 millimoles per liter are extraordinarily high and would be considered life-threatening or even fatal, said Barbara Cordell, president of an advocacy group called Auto-Brewery Syndrome Information and Research, which provides patient education and conducts research into the unusual condition.
Although no one she knows has had their alcohol level reach that level, many people can function with blood alcohol levels up to 30 millimoles per liter or 40 millimoles per liter, Cordell said in an email.
“I know of over 300 people diagnosed with auto-brewery syndrome and we have over 800 patients and caregivers in our private Facebook support group,” said Cordell, who was not involved in the new case.
“Part of the mystery of this syndrome is how these people can have extremely high levels and still walk around and talk.”
Every emergency room doctor questioned the Toronto woman’s drinking habits, and she was examined by three different hospital psychiatrists who concluded she did not meet the criteria for a diagnosis of the disorder. linked to alcohol consumption.
“She told doctors that her religion didn’t allow her to drink, and her husband checked to make sure she wasn’t drinking,” said Zewude, who treated the woman and co-wrote a report on the anonymously published case Monday in the Journal of the Canadian Medical Association.
“But it wasn’t until the seventh visit that an emergency room doctor finally said, ‘I think this looks like auto-brewery syndrome,’ and sent her to a specialist,” Zewude said .
Dr. Fahad Malik, a gastroenterologist at United Heath Services in Binghamton, New York, who currently cares for 30 patients with the disease, said in an email that it is common for patients to be treated with disbelief and ridicule. He was not involved in the new case study.
“Most patients were considered ‘closet drinkers’ or with behavioral problems before diagnosis,” said Malik, who is also a clinical assistant instructor at the Medical University of the State of New York.
Extremely rare and often overlooked
Autobrewery syndrome, also known as intestinal fermentation syndrome, is an extremely rare condition. in which bacteria and fungi in the gastrointestinal tract convert carbohydrates in everyday foods into ethanol. The first known case occurred in 1946 in Africa, when a 5-year-old boy’s stomach ruptured for no known reason. An autopsy revealed his abdomen was filled with a “foamy” fluid smelling of alcohol.
Since 1974, 20 diagnosed cases of auto-brewery syndrome have been reported in the English medical literature, according to an April 2021 review. Other reports of auto-brewery symptoms have occurred in Japan, where the condition is known as meitei-sho, or “alcohol self-poisoning syndrome.”
Auto-brewery syndrome occurs when certain species of bacteria and fungi overpopulate a person’s gut microbiome, essentially turning the gastrointestinal tract into an immobile apparatus.
Scientists believe the process takes place in the small intestine and is very different from the normal intestinal fermentation in the large intestine that gives our bodies energy.
Although a number of pathogens can contribute, most cases are caused by an overgrowth of two species of fungi: Saccharomyces and Candida. Candida lives on the body and in the mouth, digestive tract, and vagina, often taking over when more beneficial bacteria are killed by a round or two of antibiotics.
A July 2013 report documented the case of a 61-year-old man who had frequent, unexplained drunken fits for years before being diagnosed with an intestinal overabundance of Saccharomyces cerevisiae, or brewer’s yeast, the same yeast used to make beer.
Many people with the syndrome can function with a huge amount of metabolically generated alcohol in their system, sometimes only when they are in trouble with the law.
A North Carolina man, aged in his 40s, was arrested for drunk driving, cops say. He denied drinking despite having a blood alcohol level of 0.2%, the equivalent of 10 drinks per hour and around 2.5 times the legal limit.
“It’s not as rare as you think, it’s (just) rarely diagnosed,” Cordell said. “I think a lot of people can walk around in a fog and just think they’re tired when they’re fermenting alcohol.”
There are risk factors for auto-brewery syndrome. Diabetes and liver disease can play a role, as can gastrointestinal illnesses such as inflammatory bowel disease and short bowel syndrome, in which the small intestine is damaged or shortened, said Zewude. There may even be a genetic predisposition related to how a person metabolizes alcohol.
“But all of these things need to collide at the perfect time,” she said. “It takes several risk factors to interact and create a metabolic storm for this syndrome to emerge in an individual.”
For Zewude’s Toronto patient, this metabolic storm began in her mid-40s when she began having concomitant urinary tract infections, each treated with a round of antibiotics. The beneficial bacteria in his intestinal tract began to die off, allowing the fungi waiting for them to take over.
This amount of yeast needs fuel, which it gets from carbohydrates in the diet. By the time she was 48, her body was turning almost every carb she ate into alcohol.
“If she didn’t eat a lot of carbs, the symptoms weren’t so bad,” Zewude said. “But she may then have a slice of cake or another high-carb meal, causing her alcohol levels to rise quickly. These were the times when she could make lunch for her children and go to sleep.
Treatment for auto-brewery syndrome begins with a course of prescribed fungicides after a biopsy or colonoscopy identifies the specific pathogens that have colonized the gut, Zewude said. Starting with a broad-spectrum fungicide can backfire.
“Antimicrobial resistance is an important part of the syndrome because people suffer from it in part because of frequent use of antibiotics that disrupt their gut,” she said. “You have to start right, and then if the patient becomes resistant to that fungicide, try others.”
In addition to killing the yeast, patients must follow an extremely restricted, low-carb diet. “It would be better to not eat carbs, but it’s almost impossible to do that,” Zewude said. Probiotics to rebuild beneficial bacteria can also help, she said.
TToday, the woman no longer takes antifungal medications, but she continues to follow a very low-carb diet after a relapse. As each person’s experience is different, it is important that patients stay in close contact with their doctor to manage their condition, Zewude said.
“In this case, the woman has a very supportive husband, who called me immediately when he started smelling alcohol on his breath again,” Zewude said. “For anyone suffering from the syndrome, it is important that your spouse, friend, roommate or others know the signs and symptoms and contact doctors or take the person to the emergency room when it occurs.”
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