A Rare Diagnosis of Gut Fermentation/Auto-Brewery Syndrome in the Setting of Diabetes and Obesity

Gut fermentation or auto-brewery syndrome is a relatively uncommon medical condition that presents a diagnostic and therapeutic challenge. Here we present a unique case of a 45-year-old obese, male, diabetic patient treated with two courses of antibiotics for deviated nasal septum and dental procedure who reported episodes of diarrhea, vomiting, edema, seizures, hallucinations, intermittent fevers, chills, slurred speech, and loss of consciousness precipitated after meals for a duration of 14 months. The patient denied alcohol consumption at any time. His blood ethanol levels, measured on multiple occasions, were elevated and corroborated by a 24-hour meal test administered in the hospital. Small bowel and fecal contents collected during the endoscopic procedures were remarkable for the growth of Saccharomyces cerevisiae from both samples. Gram stain was negative for Salmonella, Shigella, or Campylobacter. A rapid membrane enzyme immunoassay for C difficile antigen and toxins A and B was also negative. The patient responded well to oral fluconazole but relapsed after a month and needed further assessment. Microbiological studies undertaken on gastric and small bowel contents collected during the follow-up upper and lower endoscopic procedures were positive for Candida intermedia, sensitive to fluconazole (0.250 mcg/mL) and amphotericin B (0.250 mcg/mL). Bacterial cultures showed rare, positive growth for Klebsiella pneumoniae and Enterococcus faecium. The patient responded dramatically to a no-carbohydrate diet and intravenous administration of an antifungal agent through a peripherally inserted central catheter line. The patient has been asymptomatic ever since. Auto-brewery syndrome in a setting of diabetes, obesity, and high carbohydrate intake presented with signs and symptoms of elevated serum ethanol levels. The importance of microbiological studies on carefully collected intestinal secretions is emphasized in this report, in the absence of validated diagnostic and treatment protocols in the literature.