S5695 Advanced Cirrhosis in a Patient With Suspected Auto-Brewery Syndrome and Recurrent Alcohol Intoxication-Like Episodes

Introduction: Auto-brewery syndrome (ABS) is a rare and controversial condition where endogenous fermentation leads to elevated blood alcohol levels in the absence of intake. Its diagnosis is particularly challenging in patients with known alcohol use disorder (AUD). Case Description/Methods: A 39-year-old woman with reported ABS and known AUD presented with abdominal pain, nausea, fatigue, and drowsiness. Her blood alcohol level on arrival was 493 mg/dL, declining to undetectable without documented ingestion. She developed withdrawal symptoms and was treated with CIWA protocol. Urine toxicology was positive for opiates. She was taking fluconazole, nystatin, and Lactobacillus at presentation. Prior GI evaluations were inconclusive, with a failed carbohydrate challenge and no biopsy-proven ABS. Imaging revealed cirrhosis with portal hypertension and splenomegaly. Labs showed hepatocellular injury (aspartate aminotransferase: alanine aminotransferase 2:1), hyperbilirubinemia (3.0), coagulopathy (international normalized ratio 1.4), hypoalbuminemia (2.4), and thrombocytopenia (33). Model for End-Stage Liver Disease-3.0 was 17. She exhibited grade II hepatic encephalopathy and was started on lactulose. Workup for alternative liver disease etiologies was inconclusive. Psychiatry and infectious disease were consulted for evaluation of antifungal/probiotic use and underlying behavioral concerns. Discussion: This case underscores the difficulty of diagnosing ABS in patients with coexisting AUD and advanced liver disease. A multidisciplinary approach is vital in evaluating unexplained alcohol levels and safely managing cirrhosis-related complications.