Auto-brewery syndrome

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Auto-brewery syndrome
Other namesGut fermentation syndrome, Endogenous ethanol fermentation
2401 Components of the Digestive System.jpg
Digestive system

Auto-brewery syndrome(ABS) (also known as gut fermentation syndrome, endogenous ethanol fermentation or drunkenness disease) is a condition characterized by the fermentation of ingested carbohydrates in the gastrointestinal tract of the body caused by bacteria or fungi. [1] ABS is a rare medical condition in which intoxicating quantities of ethanol are produced through endogenous fermentation within the digestive system. [2] The organisms responsible for ABS include various yeasts and bacteria, including Saccharomyces cerevisiae , S. boulardii , Candida albicans , C. tropicalis , C. krusei , C. glabrata , C. kefyr , C. parapsilosis , Klebsiella pneumoniae , and Enterococcus faecium . [1] These organisms use lactic acid fermentation or mixed acid fermentation pathways to produce an ethanol end product. [3] The ethanol generated from these pathways is absorbed in the small intestine, causing an increase in blood alcohol concentrations that produce the effects of intoxication without the consumption of alcohol. [4]

Contents

Researchers speculate the underlying causes of ABS are related to prolonged antibiotic use, [5] poor nutrition and/or diets high in carbohydrates, [6] and to pre-existing conditions such as diabetes and genetic variations that result in improper liver enzyme activity. [7] In the last case, decreased activity of aldehyde dehydrogenase can result in accumulation of ethanol in the gut, leading to fermentation. [7] Any of these conditions, alone or in combination, could cause ABS, and result in dysbiosis of the microbiome. [5]

Another variant, urinary auto-brewery syndrome, is when the fermentation occurs in the urinary bladder rather than the gut.

Claims of endogenous fermentation have been attempted as a defense against drunk driving charges, some of which have been successful, but the condition is so rare and under-researched they are currently not substantiated by available studies. [7]

Symptoms and signs

This disease can have profound effects on everyday life. Symptoms that usually accompany ABS include elevated blood alcohol levels as well as symptoms consistent with alcohol intoxication—such as slurred speech, stumbling, loss of motor functions, dizziness, and belching. [8] Mood changes and other neurological problems have also been reported. [1] Several cases in the United States and one in Belgium have argued endogenous fermentation as a defense against drunk driving. [7] [9]

Risk factors

Certain clinical conditions such as type 2 diabetes mellitus and liver cirrhosis have been identified as producing higher levels of endogenous ethanol. [4] Research has also shown that Klebsiella bacteria can similarly ferment carbohydrates to alcohol in the gut, which can accelerate non-alcoholic fatty liver disease. [10] Gut fermentation can occur in patients with short bowel syndrome after surgical resection because of fermentation of malabsorbed carbohydrates. [1]

Kaji et al. noticed a correlation between this syndrome and previous abdominal surgeries and disturbances, such as a dilation of the duodenum. Stagnation of the contents ensues, which favors proliferation of the causative organisms. [8]

Gut fermentation syndrome has been investigated, but eliminated, as a possible cause of sudden infant death syndrome. [11]

Metabolic action

Ethanol fermentation cycle Ethanol fermentation.jpg
Ethanol fermentation cycle

Fermentation is a biochemical process during which yeast and certain bacteria convert sugars to ethanol, carbon dioxide, as well as other metabolic byproducts. [12] [13] The fermentation pathway involves pyruvate formed from yeast in the EMP pathway, while some bacteria obtain pyruvate through the ED pathway. [12] Pyruvate is then decarboxylated to acetaldehyde in a reaction involving the enzyme pyruvate decarboxylase. [12] Reduction of acetaldehyde to ethanol produces NAD+, which is catalyzed by alcohol dehydrogenase (ADH). [12] ADH rids the body of alcohol through a process called first pass metabolism. [7] However, if the rate of ethanol breakdown is less than the rate of production, intoxication ensues.[ citation needed ]

Diagnosis

Alcohol levels within the body are usually detected through blood or breath. The best way to identify endogenous ethanol in the bloodstream is through gas chromatography. In gas chromatography the breath or blood is heated so that the different components of the vapor or blood separate. The volatile compounds then pass through a chromatograph that isolates ethanol from the other volatiles so that it can be quantified. [14]

More convenient methods include serum measurements and breathalyzers, especially during an acute attack at home. [10] Different countries have different baselines for blood alcohol levels when identifying intoxication through breathalyzers. In the United States it is 0.08 g/dL.[ citation needed ]

In diagnosing ABS through serum measurement methods, patients must fast in order that baseline blood alcohol and blood glucose levels can be established. They are then administered a dose of IG glucose to see if there is an increase in blood alcohol as well as blood sugar. [15] Blood glucose level can be measured with enzyme-amperometric biosensors, as well as with urine test strips. [16]  Many of these tests are performed in combination to rule out lab mistakes and alcohol ingestion so that the syndrome is not misdiagnosed. [10]

Treatment

First, patients diagnosed with ABS are treated for the immediate symptoms of alcohol intoxication. [1] Next, patients can take medications if they test positive for the types of fungi or bacteria that cause gut fermentation. For example, antifungals such as fluconazole or micafungin can be prescribed by a physician. [8] [6] [17] Often, probiotics are given concurrently to ensure that the proper bacteria recolonize the gut, and to prevent recolonization by the microorganisms that caused the syndrome. [17] Patients also typically undergo a diet therapy where they are placed on a high protein, low carbohydrate diet to avoid the symptoms of ABS. [1] The treatments listed above can be used individually or in combination to reduce the effects of the syndrome. [1]

Case studies

Related Research Articles

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Flatulence is the expulsion of gas from the intestines via the anus, commonly referred to as farting. "Flatus" is the medical word for gas generated in the stomach or bowels. A proportion of intestinal gas may be swallowed environmental air, and hence flatus is not entirely generated in the stomach or bowels. The scientific study of this area of medicine is termed flatology.

<span class="mw-page-title-main">Urinary tract infection</span> Infection that affects part of the urinary tract

A urinary tract infection (UTI) is an infection that affects a part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis). Symptoms from a lower urinary tract infection include pain with urination, frequent urination, and feeling the need to urinate despite having an empty bladder. Symptoms of a kidney infection include fever and flank pain usually in addition to the symptoms of a lower UTI. Rarely the urine may appear bloody. In the very old and the very young, symptoms may be vague or non-specific.

<span class="mw-page-title-main">Lactic acid</span> Group of stereoisomers

Lactic acid is an organic acid. It has the molecular formula CH3CH(OH)COOH. It is white in the solid state and it is miscible with water. When in the dissolved state, it forms a colorless solution. Production includes both artificial synthesis as well as natural sources. Lactic acid is an alpha-hydroxy acid (AHA) due to the presence of a hydroxyl group adjacent to the carboxyl group. It is used as a synthetic intermediate in many organic synthesis industries and in various biochemical industries. The conjugate base of lactic acid is called lactate. The name of the derived acyl group is lactoyl.

<span class="mw-page-title-main">Hematuria</span> Medical condition

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<span class="mw-page-title-main">Ethanol fermentation</span> Biological process that produces ethanol and carbon dioxide as by-products

Ethanol fermentation, also called alcoholic fermentation, is a biological process which converts sugars such as glucose, fructose, and sucrose into cellular energy, producing ethanol and carbon dioxide as by-products. Because yeasts perform this conversion in the absence of oxygen, alcoholic fermentation is considered an anaerobic process. It also takes place in some species of fish where it provides energy when oxygen is scarce.

<span class="mw-page-title-main">Small intestinal bacterial overgrowth</span> Medical condition

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<span class="mw-page-title-main">Trimethylaminuria</span> Medical condition

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<span class="mw-page-title-main">Glycosuria</span> Medical condition

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<span class="mw-page-title-main">Gitelman syndrome</span> Medical condition

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<span class="mw-page-title-main">Glucuronic acid</span> Sugar acid

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<span class="mw-page-title-main">Fermentation</span> Metabolic process producing energy in the absence of oxygen

Fermentation is a metabolic process that produces chemical changes in organic substances through the action of enzymes. In biochemistry, it is broadly defined as the extraction of energy from carbohydrates in the absence of oxygen. In food production, it may more broadly refer to any process in which the activity of microorganisms brings about a desirable change to a foodstuff or beverage. The science of fermentation is known as zymology.

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<span class="mw-page-title-main">Alcohol withdrawal syndrome</span> Medical condition

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<span class="mw-page-title-main">Purple urine bag syndrome</span> Medical condition

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<span class="mw-page-title-main">Emphysematous cystitis</span> Medical condition

Emphysematous cystitis is a rare type of infection of the bladder wall by gas-forming bacteria or fungi. The most frequent offending organism is E. coli. Other gram negative bacteria, including Klebsiella and Proteus are also commonly isolated. Fungi, such as Candida, have also been reported as causative organisms. Citrobacter and Enterococci have also been found to cause emphysematous cystitis. Although it is a rare type of bladder infection, it is the most common type of all gas-forming bladder infections. The condition is characterized by the formation of air bubbles in and around the bladder wall. The gas found in the bladder consists of nitrogen, hydrogen, oxygen, and carbon dioxide. The disease most commonly affects elderly diabetic and immunocompromised patients. The first case was identified in a post-mortem examination in 1888.

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<span class="mw-page-title-main">Alcohol (drug)</span> Active ingredient in fermented drinks

Alcohol, sometimes referred to by the chemical name ethanol, is a depressant drug found in fermented beverages such as beer, wine, and distilled spirit -- in particular, rectified spirit. Ethanol is colloquially refereed to as "alcohol" because it is the most prevalent alcohol in alcoholic beverages, but technically all alcoholic beverages contain several types of psychoactive alcohols, that are categorized as primary, secondary, or tertiary; Primary alcohols are oxidized to aldehydes, secondary alcohols undergo oxidation to form ketones, while tertiary alcohols are generally resistant to oxidation; Ethanol is a primary alcohol that has unpleasant actions in the body, many of which are mediated by its toxic metabolite acetaldehyde. Less prevalent alcohols found in alcoholic beverages, are secondary, and tertiary alcohols. For example, the tertiary alcohol 2M2B which is up to 50 times more potent than ethanol and found in trace quantities in alcoholic beverages, has been synthesized and used as a designer drug. Alcoholic beverages are sometimes laced with toxic alcohols, such as methanol and isopropyl alcohol. A mild, brief exposure to isopropyl alcohol is unlikely to cause any serious harm, but many methanol poisoning incidents have occurred through history, since methanol is lethal even in small quantities, as little as 10–15 milliliters. Ethanol is used to treat methanol and ethylene glycol toxicity.

References

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  2. ↑ Kaji H, Asanuma Y, Yahara O, Shibue H, Hisamura M, Saito N, et al. (1984). "Intragastrointestinal alcohol fermentation syndrome: report of two cases and review of the literature". Journal of the Forensic Science Society. 24 (5): 461–71. doi:10.1016/S0015-7368(84)72325-5. PMID   6520589.
  3. ↑ Fayemiwo SA, Adegboro B (2013-11-20). "Gut fermentation syndrome". African Journal of Clinical and Experimental Microbiology. 15 (1): 48–50. doi: 10.4314/ajcem.v15i1.8 . ISSN   1595-689X.
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  9. ↑ "2 promille alcohol in zijn bloed, maar toch vrijgesproken voor rijden onder invloed: man uit Brugge lijdt aan autobrouwerijsyndroom". VRT (in Dutch). 22 April 2024. Retrieved 23 April 2024.
  10. 1 2 3 Yuan J, Chen C, Cui J, Lu J, Yan C, Wei X, et al. (October 2019). "Fatty Liver Disease Caused by High-Alcohol-Producing Klebsiella pneumoniae". Cell Metabolism. 30 (4): 675–688.e7. doi: 10.1016/j.cmet.2019.08.018 . PMID   31543403.
  11. ↑ Geertinger P, Bodenhoff J, Helweg-Larsen K, Lund A (September 1982). "Endogenous alcohol production by intestinal fermentation in sudden infant death". Zeitschrift für Rechtsmedizin. Journal of Legal Medicine. 89 (3): 167–72. doi:10.1007/BF01873798. PMID   6760604. S2CID   29917601.
  12. 1 2 3 4 Fath BD, Jørgensen SE (23 August 2018). Encyclopedia of ecology. Fath, Brian D. (Second ed.). Amsterdam, Netherlands. ISBN   978-0-444-64130-4. OCLC   1054599976.{{cite book}}: CS1 maint: location missing publisher (link)
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  15. ↑ Eaton KK (November 1991). "Gut fermentation: a reappraisal of an old clinical condition with diagnostic tests and management: discussion paper". Journal of the Royal Society of Medicine. 84 (11): 669–71. doi:10.1080/13590840410001734929. PMC   1295472 . PMID   1744875.
  16. ↑ Simic M, Ajdukovic N, Veselinovic I, Mitrovic M, Djurendic-Brenesel M (March 2012). "Endogenous ethanol production in patients with diabetes mellitus as a medicolegal problem". Forensic Science International. 216 (1–3): 97–100. doi:10.1016/j.forsciint.2011.09.003. PMID   21945304.
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  18. ↑ Spinucci G, Guidetti M, Lanzoni E, Pironi L (July 2006). "Endogenous ethanol production in a patient with chronic intestinal pseudo-obstruction and small intestinal bacterial overgrowth". European Journal of Gastroenterology & Hepatology. 18 (7): 799–802. doi:10.1097/01.meg.0000223906.55245.61. PMID   16772842.
  19. ↑ Dashan A, Donovan K (August 2001). "Auto-brewery syndrome in a child with short gut syndrome: case report and review of the literature". J Pediatr Gastroenterol Nutr. 33 (2): 214–215. doi:10.1097/00005176-200108000-00024. PMID   11568528.
  20. ↑ "Auto-Brewery Syndrome: Woman Failed Urine Tests As Her Bladder Was Brewing Alcohol". International Business Times . 26 February 2020.
  21. ↑ Kruckenberg KM, DiMartini AF, Rymer JA, Pasculle AW, Tamama K (February 2020). "Urinary Auto-brewery Syndrome: A Case Report". Annals of Internal Medicine. 172 (10): 702–704. doi:10.7326/L19-0661. PMID   32092761. S2CID   211475605.
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