S5924 Hyperlocal Brewery: Cases and Comprehensive Review of the Clinical Course, Diagnosis, and Treatment of Autobrewery Syndrome

Introduction: Auto-brewery syndrome (ABS) is a rare condition characterized by endogenous ethanol production through the fermentation of carbohydrates by fungi or bacteria within the gastrointestinal tract, oral cavity, or urinary system. This process can result in a spectrum of symptoms associated with alcohol intoxication—including confusion, slurred speech, and imbalance—often in the absence of alcohol consumption. Triggering factors include fasting, stress, or can be idiopathic, complicating diagnosis and management. We present 2 cases of ABS in which patients exhibited hallmark symptoms and biochemical evidence of ethanol presence without alcohol intake, both of whom improved with antifungal treatment and lifestyle changes. Case Description/Methods: Patient A, a 36-year-old man with no metabolic risk factors, reported episodes of confusion and slurred speech following fasting. Despite negative brain imaging and glucose monitoring, he had persistently elevated liver enzymes, a positive phosphatidylethanol (PETH) test, and hepatic steatosis on imaging. A liver biopsy confirmed steatohepatitis with fibrosis. He was treated with 2 14-day courses of fluconazole and initiated a low-carbohydrate diet, resulting in full clinical and biochemical remission, including normalization of liver enzymes, PETH levels, and resolution of steatosis on imaging. Patient B, a 58-year-old man, experienced episodes of brain fog and inebriation-like symptoms triggered by stress and fasting. He exhibited mild hepatic steatosis, transient liver enzyme elevation, and fungal elements on endoscopic culture. He responded favorably to 3 courses of fluconazole, a low-carbohydrate diet, alcohol abstinence, and probiotic use. Discussion: These cases underscore the importance of considering ABS in patients with unexplained inebriation symptoms, particularly when traditional risk factors for liver disease are absent. While formal diagnostic criteria are not well-established, suggestive findings—such as positive PETH, abnormal liver studies, and symptom resolution following antifungal therapy—support the diagnosis. Management typically involves antifungal agents, dietary modification, and ongoing symptom surveillance. Increased awareness and early recognition of ABS are essential. Appropriate diagnosis and treatment may prevent progression to irreversible liver damage and significantly improve patient quality of life.