• DOI:10.7326/L19-0661
• Corpus ID: 211475605

Urinary Auto-brewery Syndrome: A Case Report

@article{Kruckenberg2020UrinaryAS,
  title={Urinary Auto-brewery Syndrome: A Case Report},
  author={Katherine M Kruckenberg and Andrea F. Dimartini and Jacqueline A. Rymer and Anthony W. Pasculle and Kenichi Tamama},
  journal={Annals of Internal Medicine},
  year={2020},
  volume={172},
  pages={702 - 704}
}

• Katherine M Kruckenberg, A. Dimartini, +2 authors K. Tamama
• Published 25 February 2020
• Medicine
• Annals of Internal Medicine

Background: Auto-brewery syndrome is a rare medical condition in which intoxicating quantities of ethanol are produced by specific types of yeast or bacteria through endogenous fermentation in the digestive system (1). Objective: To alert clinicians to the possibility of a previously unrecognized auto-brewery syndrome in which ethanol is produced through endogenous fermentation in the urinary system. Case Report: A 61-year-old woman with cirrhosis and poorly controlled diabetes presented to our center for placement on the liver transplant waitlist. Previously, clinicians at another hospital advised her to obtain treatment for alcohol addiction instead of placing her on their center's liver transplant waitlist because urine tests for alcohol were repeatedly positive. Initially, our encounters were similar, leading our clinicians to believe that she was hiding an alcohol use disorder. However, we noted that plasma test results for ethanol and urine test results for ethyl glucuronide and ethyl sulfate, which are the metabolites of ethanol (2), were negative, whereas urine test results for ethanol were positive (Table). In addition, the patient did not have alcohol intoxication symptoms during clinic visits, despite urine ethanol values greater than 39.1 mmol/L (>180 mg/dL). Moreover, she consistently denied alcohol consumption. Besides these discrepancies, we also noticed that she frequently had hyperglycosuria (≥55.5 mmol/L [≥1000 mg/dL]) with abundant budding yeast in urine samples (Table). These findings led us to test whether yeast colonizing in the bladder could ferment sugar to produce ethanol (3). The Figure describes the in vitro experiment we used to demonstrate remarkably high levels of ethanol production (3.9 mmol/L [18 mg/dL] per hour at 25 °C and 6.9 mmol/L [32 mg/dL] per hour at 37 °C) in the patient's freshly voided urine. As a result, we concluded that the discrepant test results were best explained by yeast fermenting sugar in the bladder. We identified the yeast as Candida glabrata, which is part of the normal body flora and is closely related to brewer yeast or Saccharomyces cerevisiae (4). We tried eliminating this yeast using an oral antifungal regimen but it was unsuccessful, presumably because of the patient's poorly controlled diabetes. As a result of our experiment and new appreciation for her pathophysiology, she was reconsidered for liver transplantation. Discussion: Production of ethanol through fermentation of yeast in the urine of patients with poorly controlled diabetes has been reported elsewhere, but these reports are limited to 1 postmortem case and in vitro conditions (3). We have not found a similar report of yeast producing ethanol by fermenting sugar in the bladder. We propose calling this phenomenon “urinary auto-brewery syndrome,” or “bladder fermentation syndrome.” This syndrome is similar to but distinct from the traditional auto-brewery syndrome, which is also known as “gut fermentation syndrome” (1), whereby alcohol is generated by fermenters in the gastrointestinal tract, producing a positive plasma ethanol level and causing symptoms of intoxication. The experience we describe here of 2 liver transplant teams at different institutions demonstrates how easy it is to LETTERS