(CNN) — His breath reeked of alcohol. She was dizzy, disoriented and weak, to the point that one day she fainted and hit her head on the kitchen counter while she was preparing food for her young children.
However, not a drop of alcohol had passed her lips, a fact the 50-year-old Toronto woman and her husband told doctors for two years before anyone actually believed her.
“He visited his primary care doctor over and over again and went to the emergency room seven times over two years,” explains Dr. Rahel Zewude, an infectious disease specialist at the University of Toronto.
Doctors discovered that the woman’s blood alcohol levels could range between 30 millimoles per liter and 62 millimoles per liter; below 2 millimoles per liter is normal, Zewude said.
Alcohol levels of up to 62 millimoles per liter are extraordinarily high and would be considered potentially dangerous, even fatal, said Barbara Cordell, president of an advocacy association called Auto-Brewery Syndrome Information and Research, which provides patient education and conducts research. about the unusual condition.
Although no one she knows has had alcohol levels that reach that level, many people can function with blood alcohol levels as high as 30 millimoles per liter or 40 millimoles per liter, Cordell said in an email.
“I know over 300 people diagnosed with ABS 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 these extremely high levels and still walk and talk.”
All emergency room doctors questioned the drinking habits of the Toronto woman, who was examined by three different hospital psychiatrists, who concluded that she did not meet the criteria for a diagnosis of an alcohol use disorder.
“She told the doctors that her religion did not allow her to drink, and her husband verified that she did not drink,” explains Zewude, who treated the woman and is co-author of a report on the anonymous case published Monday in the academic journal Canadian Medical Association. Journal.
“But it wasn’t until the seventh visit that an emergency room doctor finally said, ‘I think this sounds like intestinal fermentation syndrome,’ and referred her to a specialist,” Zewude explained.
Dr. Fahad Malik, a gastroenterologist at United Heath Services in Binghamton, New York, who currently has 30 patients with the disorder, said in an email that being treated with disbelief and ridicule is common for patients. He was not involved in the new study.
“Prior to diagnosis, most patients were considered ‘closet drinkers’ or conduct disordered,” says Malik, who is also an adjunct clinical instructor at the State University of New York Upstate Medical University.
Extremely rare and often unrecognized
Gut fermentation syndrome is an extremely rare condition in which bacteria and fungi in the gastrointestinal tract convert carbohydrates from everyday foods into ethanol. The first documented case occurred in 1946 in Africa, when a 5-year-old boy’s stomach ruptured for no known reason. The autopsy revealed that his abdomen was filled with a “foamy” liquid that smelled like alcohol.
According to a medical review from April 2021, 20 diagnosed cases of intestinal fermentation syndrome have been reported in the English medical literature since 1974. Other reports of symptoms of this syndrome have occurred in Japan, where the condition is known as meitei-sho, or “alcohol autointoxication syndrome.”
Gut fermentation syndrome occurs when certain species of bacteria and fungi overpopulate a person’s gut microbiome, essentially turning the gastrointestinal tract into a distillation apparatus.
Scientists believe that the process takes place in the small intestine and is very different from the normal intestinal fermentation in the large intestine that gives our body energy.
Although several pathogens can contribute, most cases are due to overgrowth of two fungal species: Saccharomyces and Candida. Candida lives in the body and in the mouth, digestive tract and vagina, and often takes over when the most 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 episodes of unexplained drunkenness for years before being diagnosed with an intestinal overabundance of Saccharomyces cerevisiaethe same yeast used to make beer.
Many people with this syndrome can function with an enormous amount of metabolically generated alcohol in their system, and sometimes only realize this when they are in trouble with the law.
A North Carolina man in his 40s was arrested for drunk driving. He denied drinking despite having a blood alcohol level of 0.2%, the equivalent of consuming 10 drinks an hour and about 2.5 times the legal limit.
“It’s not as rare as we think, it’s (only) rarely diagnosed,” Cordell said. “I think a lot of people can walk around feeling groggy and just think they’re tired when they could be fermenting alcohol.”
A “metabolic storm”
There are risk factors for intestinal fermentation syndrome. Diabetes and liver disease can play a role, as can gastrointestinal diseases such as inflammatory bowel disease and short bowel syndrome, in which the small intestine is damaged or shortened, Zewude explains. There may even be a genetic predisposition related to the way a person metabolizes alcohol.
“But all of these factors have to come together at the perfect time,” he says. “It takes multiple risk factors that interact and create a metabolic storm for this syndrome to arise in an individual.”
In the case of Zewude’s patient, that metabolic storm began around age 40, when she began having simultaneous urinary tract infections, each treated with a round of antibiotics. The beneficial bacteria in her intestinal tract began to disappear, allowing lurking fungi to take over.
That much yeast needs fuel, which it gets from dietary carbohydrates. At 48 years old, his body transformed almost all carbohydrates into alcohol.
“If I didn’t eat a lot of carbohydrates, the symptoms weren’t as bad,” Zewude explains. “But if she ate a piece of cake or another carbohydrate-rich food, the alcohol level rose quickly. Those were the times when she could be preparing food for her children and fall asleep.”
According to Zewude, treatment for autoinflammation syndrome begins with a course of prescribed fungicides after a biopsy or colonoscopy identifies the specific pathogens that have colonized the intestine. Starting with a broad-spectrum fungicide can be counterproductive.
“Antibiotic resistance is an important part of the syndrome, because part of the reason people have this is because frequent antibiotic use disrupts their gut,” he said. “You have to start small, and then, if the patient becomes resistant to that fungicide, try others.”
In addition to killing off the yeast, patients must follow an extremely restricted, low-carbohydrate diet. “It would be best not to eat carbohydrates, but it is almost impossible,” says Zewude. Probiotics can also help to recover beneficial bacteria.
The woman is no longer taking antifungal medications, but continues to follow a very low-carbohydrate diet after suffering a relapse. Because everyone’s experience is different, it’s important for patients to stay in constant contact with their doctors to manage their illness, Zewude explains.
“In this case, the woman has a very understanding husband, who called me immediately when he started smelling alcohol on her breath again,” Zewude said. “For anyone dealing with this syndrome, it is important that their spouse, friend, roommate or whatever, know the signs and symptoms and contact doctors or take the person to the emergency room when this occurs. happen.”
