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A Toronto woman was taken to the emergency room seven times over a two year period with signs of alcohol intoxication. The problem? She had never actually drank a sip of alcohol.
According to a new article published in the Canadian Medical Association Journal, a 50-year-old woman visited both her family physician and emergency rooms complaining of drowsiness and falling asleep suddenly while preparing meals for her children or getting ready for work. The woman, who had slurred speech and the smell of alcohol on her breath, said she would become so drowsy she would fall, but insisted she did not drink alcohol.
After each visit, the woman was diagnosed with alcohol intoxication. Her symptoms persisted — the woman and her husband assured healthcare providers that although she had previously drank a glass of wine during the holidays, in recent years she stopped drinking alcohol due to religious beliefs.
The wider medical community is not very familiar with the syndromeDr. Rahel Zewude
On her seventh visit to the emergency room, the woman had a blood alcohol level of 62 mmol/L (alcohol-related fatalities typically occur when levels are above 86.8 mmol/L). Her emergency room physician believed the woman and her husband when they said she didn’t drink alcohol, and suspected she might have auto-brewery syndrome, a condition that causes the body to convert carbohydrates to ethanol.
Dr. Rahel Zewude, an infectious diseases specialist and medical microbiology fellow at University of Toronto, who conceptualized the CMAJ study, told Yahoo Canada that the condition is “very rare.”
“The wider medical community is not very familiar with the syndrome,” she said. “That was the main reason we wanted to ensure that this report was disseminated.”
What is auto-brewery syndrome?
According to the report, auto-brewery syndrome occurs when “microorganisms capable of fermenting alcohol outgrow normal gut flora.” People with the syndrome would become intoxicated and appear drunk without actually consuming alcohol.
A 'distressing' journey to diagnosis
Prior to being referred to a gastroenterologist who confirmed the auto-brewery diagnosis, it was a difficult journey for the Canadian woman. She was assessed by three separate psychiatrists who “provided care related to addiction medicine.” According to the study, during her third visit to the emergency room, she received certification under the Mental Health Act, which allows physicians to provide care for mental health disorders against a person’s will. The woman’s physicians reportedly had concerns for “self-neglect” when the woman attempted to discharge herself without a psychiatric assessment.
It’s a testament to her spouse who was continuously supportive of her...Dr. Zewude
“It was very distressing for her to continue going to emergency rooms seven times before receiving a diagnosis and being so adamant and clear that she was not drinking anything — but she was behaving exactly like someone who drank…” Zewude said. “It’s a testament to her spouse who was continuously supportive of her and it’s a testament to the emergency room physician Dr. Goldman who believed her and gave her this diagnosis.”
Why do some people develop auto-brewery syndrome and not others?
According to Zewude, who treated the woman, there needs to be a perfect storm of conditions for someone to develop auto-brewery syndrome.
“Our hypothesis is that there are multiple factors that need to interact all at once for the syndrome to occur,” Zewude told Yahoo Canada. “There are comorbidities that patients with auto-brewery syndrome have been noted to have more than others, things like diabetes, inflammatory bowel disease and liver disease. All of these can contribute to the emergency of the syndrome because they affect our gut mobility and ability to clear and metabolize alcohol properly.”
In the case of the Toronto woman, there was no evidence of diabetes or inflammatory bowel disease. However, the woman did have a history of recurring urinary tract infections (UTIs) for several years that required antibiotics that Zewude believes contributed to the destruction of the gut microbiome, however its speculated that there may be a genetic predisposition to the illness as well.
How do you treat auto-brewery syndrome?
The woman’s emergency room physician prescribed Fluconazole, an oral medication that’s used to treat fungal and yeast infections. As part of the gastroenterology clinic referral, a dietitian advised her to follow a low-carb diet which led to an improvement of her symptoms for 4 months. Once she began increasing carb intake, she experienced symptoms once again and suffered a fall, which prompted her to resume taking Fluconazole, followed a low-carb diet and she was prescribed probiotics to restore her gut health.
“This is a rare syndrome and what we do has to be absolutely tailored to the patient's interests and lifestyle,” Zewude said. “Some patients are so distressed by the episodes that they had, that they would say, ‘I would rather have this low-carb diet for the rest of my life if it means that I wouldn't ever experience that again.’”
Zewude continues to monitor the woman, who is “managing well” with a low-carb diet. However, it will be an “ongoing conversation” with the patient.
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