The Auto-Brewery Syndrome: A Perfect Metabolic "Storm" with Clinical and Forensic Implications

Abstract

Auto-brewery syndrome (ABS) is a rare, unstudied, unknown, and underreported phenomenon in modern medicine. Patients with this syndrome become inebriated and may suffer the medical and social implications of alcoholism, including arrest for inebriated driving. The pathophysiology of ABS is reportedly due to a fungal type dysbiosis of the gut that ferments some carbohydrates into ethanol and may mimic a food allergy or intolerance. This syndrome should be considered in patients with chronic obstruction or hypomotility presenting with elevated breath and blood alcohol concentrations, especially after a high carbohydrate intake. A glucose challenge test should be performed as the confirmatory test. Treatment typically includes antifungal drugs combined with changes in lifestyle and nutrition. Additional studies are particularly needed on the human microbiome to shed light on how imbalances of commensal bacteria in the gut allow yeast to colonize on a pathological level.

Keywords: Saccharomyces cerevisiae; auto-brewery syndrome; diagnosis; endogenous ethanol; fungi; gut microbiome; pathophysiology; yeast.

Figure 1

Yeast and bacterial fermentation process of the metabolism of glucose to ethanol. First, glucose is transported into the cell by the hexose transporter (HT). The process then involves the decarboxylation of pyruvic acid to acetaldehyde under anaerobic conditions, followed by the reduction of acetaldehyde to ethanol. ADH, alcohol dehydrogenase; ADP, adenosine diphosphate; ATP, adenosine triphosphate; NAD⁺, nicotinamide adenine dinucleotide; P, phosphate; PHD, pyruvate decarboxylase (an enzyme absent in humans but present in certain yeasts and bacteria); TPP, thiamine pyrophosphate.