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International Journal of Clinical Medicine, 2013, 4, 309-312
doi:10.4236/ijcm.2013.47054 Published Online July 2013 ( A Case Study of Gut Fermentation Syndrome
(Auto-Brewery) with Saccharomyces cerevisiae

as the Causative Organism

Barbara Cordell, Justin McCarthy
Panola College, Carthage, USA. Email: Received April 25th, 2013; revised May 30th, 2013; accepted June 12th, 2013 Copyright 2013 Barbara Cordell, Justin McCarthy. This is an open access article distributed under the Creative Commons Attribu-tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT
Gut Fermentation Syndrome also known as Auto-Brewery Syndrome is a relatively unknown phenomenon in modern
medicine. Very few articles have been written on the syndrome and most of them are anecdotal. This article presents a
case study of a 61 years old male with a well documented case of Gut Fermentation Syndrome verified with glucose
and carbohydrate challenges. Stool cultures demonstrated the causative organism as Saccharomyces cerevisiae. The
patient was treated with antifungals and a low carbohydrate diet and the syndrome resolved. Helicobacter pylori was
also found and could have been a possible confounding variable although the symptoms resolved post-treatment of the S.
Keywords: Auto-Brewey; Yeast; Fermentation; Gut Fermentation Syndrome
1. Introduction
In 1976, Kaji and others [2] described the case of a 24 years old female who became intoxicated after consum- Gut Fermentation Syndromeis a relatively unknown phe- ing carbohydrates which fermented in the gastrointestinal nomenon in Western Medicine. This syndrome is diffi- tract. In this situation the causative organisms were de- cult to research since it goes by several other names such termined by cultures to be Candida albicans and Can- as Auto-Brewery Syndrome and Endogenous Ethanol dida krusei. This patient restricted her intake of carbohy- Fermentation. Most of the articles published on this syn- drates in the diet and received a course of an antifungal drome are anecdotal. A few cases site yeast as the causa- agent whereby all symptoms of her intoxication sub- tive agent; in particular Candida albicans, Candida kru- sei, Candida glabrata, and Saccharomyces cerevisiae. Only a few cases have been reported in the last three This article describes the case history of a 61 years old decades. Two cases of particular note were identified in male from early symptoms, through diagnosis and treat- children. Dahshan and Donovan [3] described the case of a 13 years old girl with short gut syndrome who became intoxicated after ingesting carbohydrates. She had been 2. Review of Literature
placed in a rehabilitation facility with no access to alco- Gut Fermentation Syndrome is described as a syndrome hol. Aspirates from her small intestines grew Candida whereby patients become intoxicated without ingesting glabrata and Saccharomyces cerevisiae. After treatment alcohol. In addition to the term Auto-Brewery, this syn- with fluconazole, the symptoms resolved. The other case drome has also been called Drunkenness Disease and [4] was a 3 years old girl with short bowel syndrome who Endogenous Ethanol Fermentation. The underlying me- became intoxicated after ingesting a carbohydrate-rich chanism is thought to be an overgrowth of yeast in the fruit drink. Cultures from the gastric fluids demonstrated gut whereby the yeast ferments carbohydrates into etha- Candida kefyr and Saccharomyces cerevisiae. Again a nol. The earliest cases of this phenomenon were de- course of fluconazole eliminated the symptoms. scribed in Japan. Iwata [1] detailed 12 cases prior to 1972. Hunnisett and Howard [5] proposed a clinical test in Copyright 2013 SciRes. IJCM
A Case Study of Gut Fermentation Syndrome (Auto-Brewery) with Saccharomyces cerevisiae 1990 to test for dietary fermentation. Subjects suspected would seem intoxicated without having been drinking. of gut fermentation syndrome were given a fasting glu- His wife, who is a nurse, began to document this phe- cose challenge of 5 Gm glucose orally. One gram of glu- nomenon with a DOT approved alcohol breathalyzer. cose was given in a hardened gelatin capsule to ensure Often his blood alcohol percent was as high as 0.33 to passage into the duodenum. Blood glucose levels and 0.40. The legal limit for alcohol in the United States is blood ethanol levels were measured at 1 hour. Fasting 0.08 percent. They could find no correlation to these blood alcohol levels were zero in nearly all subjects but episodes other than scant ingestion of alcohol such as 61% of the 510 subjects showed an increase in blood from a piece of gum with alcohol sugar or a candy with alcohol levels on the average of 2.5 mg/dl (range 1.0 - chocolate liqueur as an ingredient. The episodes were 7.0 mg/dl). This compared to near zero blood alcohol more frequent when a meal was missed, after exercise, or levels in the control group given the same challenge. when alcohol had been ingested the night before. Eaton [6] also summarized the phenomenon of gut fer- The episodes of intoxication began to increase in se- mentation with the above proposed diagnostic methods. verity and frequency over the ensuing years. In Novem- A study of 1557 residents of the United Arab Emirates ber of 2009, the subject was taken to the Emergency [7] determined that fermentation of ethanol was “too low room on a day when he had not ingested alcohol. In the to have any forensic significance” (p. 149). However, it ER, his blood alcohol concentration was 371 (0.37%). He is important to note that the pooled maximum blood al- was admitted to the hospital for 24-hour observation and cohol level was 3.52 mg/dl (0.035%) in males and 3.20 treated for severe alcohol intoxication. The physicians mg/dl (0.032%) in females. With zero tolerance of alco- were not aware of any way that a person could be intoxi- hol in the United Arab Emirates, there is no allowed legal cated without ingesting alcohol and therefore believed he More recently abnormal or unusual fermentation has In January of 2010, the patient presented to a gastro- been discussed in relation to high fiber diets [8], the use enterology practice where he underwent a complete gas- of ampicillin [9], and ingestion of prebiotic inulin [10]. troenterology workup. The patient had a history of hy- Furthermore, Bivin and Heinen [11] conducted an ex- pertension and hyperlipidemia. His blood pressure was periment combining five infant food formulas and/or sup- being treated but was not well controlled. All other sys- plements with four common yeasts (C. albicans, C. tro- tems were negative. The patient denied taking any type picalis, Torulopsisglabrata, and S. cerevisiae) to measure of yeast as nutritional supplementation such as probiotics ethanol production in vitro. All of the mixtures of yeast and denied previous gastrointestinal disorders or treat- and carbohydrate produced ethanol with the S. cerevisiae ments. Initially, routine breath tests were conducted for lactose and fructose intolerance as well as hydrogen and all were negative. A glucose tolerance was performed Saccharomyces cerevisiae, also known as brewer’s and was also negative. An EGD (esophagogastroduode- yeast, has a very well known history and life cycle be- noscopy) and colonoscopy were conducted and were ne- cause of the brewing industry. More recently the entire gative, however, Helicobacter pylori was isolated from genome of S. cerevisiae has been identified due to its his stomach. Stool cultures were also conducted that important use in fermenting corn into ethanol for fuel were positive for rare budding yeast and Saccharomyces consumption. Very little is known, however, about the role of S. cerevisiae in humans. In fact, S. cerevisiae has In April of 2010 the patient was admitted to the hospi- been described only recently as an “emerging infectious tal for a 24-hour observation period. His belongings were disease” [12,13]. S. cerevisiae has mostly been identified inspected to insure he did not have alcohol with him and as a pathogen in critically ill patients who are immuno- no visitors were allowed during the 24-hour period. A compromised [14,15] and in infants [16]. Not one single glucose challenge was administered along with a high article could be found on an S. cerevisiae infection in an carbohydrate diet with snacks throughout the day. Blood otherwise healthy, immuno-competent adult (Medline, was drawn for blood alcohol concentration (BAC) levels at baseline and every 2 hours and glucose levels every four hours. Breathalyzer levels were supervised by Texas 3. Case History
DPS (Department of Public Safety) officers. At one point A 61 years old male, presented in January of 2010 with during the afternoon, the patient’s BAC rose to 120 mg/dl at least a five-year history of unexplained intoxication. In (0.12% per breathalyzer) in this controlled situation. 2004, after surgery for a broken foot, and subsequent Unlike other case studies reported, fermentation in this treatment with antibiotics, he began to seem excessively case often occurred nearly 24 hours after the ingestion of intoxicated after only two beers, and on occasion he Copyright 2013 SciRes. IJCM
A Case Study of Gut Fermentation Syndrome (Auto-Brewery) with Saccharomyces cerevisiae 4. Treatment
lin, “Endogenous Ethanol Fermentation in a Child with Short Bowel Syndrome,” Acta Paediatrica, Vol. 95, No. The patient was given an oral course of fluconazole (Diflucan) 100 mg a day for three weeks followed by a [5] A. Hunnisett and J. Howard, “Gut Fermentation (or the three week course of Nystatin 500,000 IU 4 times a day. ‘Auto-Brewery’) Syndrome: A New Clinical Test with He also took daily Acidophilus tablets to re-colonize the Initial Observations and Discussion of Clinical and Bio- gut. During this six week period, the patient followed a chemical Implications,” Journal of Nutritional Medicine, very strict no sugar, no carbohydrate diet and did not ingest alcohol in any form. His breath alcohol level was tested frequently throughout each day and was 0.00 from [6] K. Eaton, “Gut Fermentation: A Reappraisal of an Old Clinical Condition with Diagnostic Tests and Manage- the time treatment began until 10 weeks later. Stool cul- ment: Discussion Paper,” Journal of the Royal Society of tures were then repeated and returned negative. Finally, Medicine, Vol. 84, No. 11, 1991, pp. 669-671. the patient was treated with a course of Tetracycline for [7] A. Al-Awadhi, I. Wasfi, F. Al-Reyami and Z. Al-Hatali, “Autobrewing Revisited: Endogenous Concentrations of Blood Ethanol in Residents of the United Arab Emirates,” 5. Conclusion
Science and Justice, Vol. 44, No. 3, 2004, pp. 149-152. The authors believe this patient had Gut Fermentation [8] S. Fleming, D. Marthinsen and H. Kuhnlein, “Colonic Syndrome as documented informally by his wife and Function and Fermentation in Men Consuming High Fi- verified formally by the hospitalization glucose challenge ber Diets,” Journal of Nutrition, Vol. 113, No. 12, 1983, and documentation of alcohol levels. The stool culture suggests that Saccharomyces cerevisiae was the causa- tive agent and the fact that the stool cultures were nega- tive for S. cerevisiae after treatment and the symptoms [9] S. Rao, C. Edwards, C. Austen, C. Bruce and N. Read, “Impaired Colonic Fermentation of Carbohydrate after subsided at that time, supports this hypothesis. This is a Ampicillin,” Gastroenterology, Vol. 94, No. 4, 1988, pp. rare syndrome but should be recognized because of the social implications such as loss of job, relationship diffi- [10] J. Sauer, K. Richter and B. Pool-Zobel, “Products Formed culties, stigma, and even possible arrest and incarceration. during Fermentation of the Prebiotic Inulin with Human It would behoove health care providers to listen more Gut Flora Enhance Expression of Biotransformation Genes carefully to the intoxicated patient who denies ingesting in Human Primary Colon Cells,” British Journal of Nutri- alcohol. Gut Fermentation Syndrome warrants additional tion, Vol. 97, No. 5, 2007, pp. 928-938. investigation to determine which organisms induce symp- toms and what definitive tests should be conducted to [11] W. Bivin and B. Heinen, “Production of Ethanol from Infant Food Formulas by Common Yeasts,” Journal of confirm diagnosis. In addition, research would be impor- Applied Bacteriology, Vol. 58, No. 4, 1985, pp. 355-357. tant to determine how overgrowth occurs with S. cere- visiae when it is normally found as a commensal in the [12] A. Enache-Angoulvant and C. Hennequin, “Invasive Sac- charomyces Infection: A Comprehensive Review,” Cli- nical Infectious Diseases, Vol. 41, No. 11, 2005, pp. 1559- 1568. REFERENCES
[13] P. Munoz, E. Bouza, M. Cuenca-Estrella, J. Eiros, M. [1] K. Iwata, “A Review of the Literature on Drunken Syn- Perez, M. Sanchez-Somolinos, C. Rincon, J. Horta and T. dromes Due to Yeasts in the Gastrointestinal Tract,” Uni- Pelaez, “Saccharomyces cerevisiae Fungemia: An Emerg- versity of Tokyo Press, Tokyo, 1972, pp. 260-268. ing Infectious Disease,” Clinical Infectious Diseases, Vol. [2] H. Kaji, Y. Asanuma, H. Ide, N. Saito, M. Hisamura, M. Murao, T. Yoshida and K. Takahashi, “The Auto-Brewe- [14] A. Riquelme, M. Calvo, A. Guzman, et al., “Saccharo- ry Syndrome—The Repeated Attacks of Alcoholic In- myces cerevisiae Fungemia after Saccharomyces bou- toxication Due to the Overgrowth of Candida (Albicans) lardii Treatment in Immunocompromised Patients,” Jour- in the Gastrointestinal Tract,” Materia Medica Polona, nal of Clinical Gastroenterology, Vol. 36, No. 1, 2002, pp. [3] A. Dahshan and K. Donovan, “Auto-Brewery Syndrome [15] W. Olver, S. James, A. Lennard, A. Galloway, T. Roberts, in a Child with Short Gut Syndrome: Case Report and T. Boswell and N. Russell, “Nosocomial Transmission of Review of the Literature,” Journal of Pediatric Gastro- Saccharomyces cerevisiae in Bone Marrow Transplant enterology and Nutrition, Vol. 33, No. 2, 2001, pp. 214- Patients,” Journal of Hospital Infection, Vol. 52, No. 4, [4] E. Jansson-Nettelbladt, S. Meurling, B. Petrini and J. Sjo- [16] J. Perapoch, A. Planes, A. Querol, V. Lopez, I. Martinez- Copyright 2013 SciRes. IJCM
A Case Study of Gut Fermentation Syndrome (Auto-Brewery) with Saccharomyces cerevisiae Bendayan, R. Tormo, F. Fernandez, G. Peguero and S. with Ultra-Levura,” European Journal of Clinical Micro- Salcedo, “Fungemia with Saccharomyces cerevisiae in biology and Infectious Diseases, Vol. 19, No. 6, 2000, pp. Two Newborns, Only One of Whom Had Been Treated Copyright 2013 SciRes. IJCM



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