Fermentation
Want to know what ingredient in beer other than alcohol causes disease in humans? What might be defense attorneys favorite medical diagnosis? Why everyone has a positive blood alcohol level, even if they don’t drink a drop?
This is the Pick Your Poison podcast. I’m your host Dr. JP and I’m here to share my passion for poisons in this interactive show. Will our patient survive this podcast? It’s up to you and the choices you make. Want to know what ingredient in beer other than alcohol causes disease in humans? What might be defense attorneys favorite medical diagnosis? Why everyone has a positive blood alcohol level, even if they don’t drink a drop?
Today's episode starts in the emergency department. It's a busy Saturday evening shift with the usual motor vehicle accidents, gunshot wounds, and drug overdoses. You're standing at the nurse’s station updating the charge nurse so she can manage the patient flow.
The ambulance doors whoosh open, the police walk in with a patient lurching unsteadily between them and in handcuffs. Intox they say. Meaning alcohol intoxication.
You suck in a surprised breath and whisper to the charge nurse, “Don't assign this one to me.”
She looks at the computer and says, "Sorry, you're up next.”
The police shuffle the person down the hall to the room. Your All-Star intern is already juggling several sick patients, nevertheless she starts to go into the room. You frantically wave her away and go in yourself.
Doorway diagnosis is a skill we EM physicians develop. Basically a quick assessment of sick or not sick as the patient rolls past. This patient is awake and walking. Assuming the police are correct about alcohol intoxication, it’s certainly not an emergency and the patient can wait to be seen. So why are you rushing in and waving off the intern who is supposed to see everyone first?
Because you know this patient. She’s your colleague. One of the other emergency medicine physicians. It’s the reason you wanted absolutely nothing to do with this case. Medically speaking it doesn’t look like much of a challenge. Ethically, it’s fraught with pitfalls. You’ll have to balance her privacy, critical, with a raft of ethical questions you probably can’t answer. You take a deep breath and steel yourself to enter the room. She’s laying on the stretcher, with one arm handcuffed to the side rail.
“Hi, how's it going?” You say awkwardly. You didn't learn the appropriate bedside manner for this in residency. “So why don't you tell me what happened?”
Your colleague looks at the police; the police look at her.
The police say she's under arrest for a DUI, driving under the influence. They brought her here to sober up and to obtain a blood alcohol level or a BAL for short. Why did they bring her to the hospital, not to jail? Probably they're about as excited as you are to be involved in this case, arresting an ER doctor for drunk driving. In the old days patients went to the drunk tank and unfortunately sometimes died there. You can, of course, die from a high alcohol level, but this isn't super common. What happened more often was patients presumed to be drunk had intercranial hemorrhages or other illnesses and died without medical care. These days while the police can take intoxicated people directly to jail, they often bring them to the hospital first.
In the ED, we can order a blood alcohol on any patient, anytime and we often do for medical reasons, but it’s generally inadmissible in court. Why? There’s no chain of custody. What’s that? Patients with elevated blood alcohol levels have successfully argued in court specimens were contaminated in the lab, mixed up with someone else’s etc. To avoid this, for legal purposes, chain of custody means the specimen has to stay with the police themselves or under strict protocols to ensure no errors and admissibility in court. This means, in general in the US, if the police want a BAL they call their own nurse to come obtain it, following chain of custody.
Which brings us a question number one what test do we need stat?
A. a blood alcohol level.
B. blood glucose.
C. Liver function tests.
D. Blood pressure
The answer is B. we need an emergent blood sugar. Your colleague has diabetes. We need to make sure this isn’t hypoglycemia or low glucose. You can send a blood alcohol level if you want, we'll come back and talk about these in more detail, but it's not emergent. Chronic alcoholics can have elevated liver function, obviously, but this isn’t emergent either.
It is astonishing how closely hypoglycemia can mimic alcohol intoxication. I once had a patient brought in under arrest by the police after a car accident. She looked and sounded drunk, lurching around, slurred speech. She kept trying to get up off the stretcher and leave. She had a history of diabetes, so the first thing we did was a blood sugar it was extremely low 20 mg/dL, normal is 70 to 100 mg/dL. (Her blood sugar was 1 mmol/L if you use those units.) As soon as the police saw this, they literally took the handcuffs off and walked out of the emergency department. After treatment with glucose, she was completely normal in a matter of minutes.
Fortunately, or unfortunately, for your colleague, her blood sugar is 80mg/dL. Normal. You ask her what happened, she said she was driving home from a restaurant when she was pulled over. The officers said she was driving erratically and accused her of drunk driving. She agreed to a breathalyzer test, certain it would be normal because she hadn't had any drinks. She was shocked when it was high.
What do you think about this? Do you believe her? We hear this story a lot from patients whose alcohol levels come back positive. That said, I don’t expect to hear it from a colleague. But the stakes are high. If you are a physician and get a DUI, regulations vary, in most cases it has to be reported to medical licensing boards.
You asked the police officers to step out. You tell her what she says will be confidential, you won't put it in her chart. She says the exact same thing and again denies drinking.
How do we manage intoxicated patients in the emergency department? The main treatment is observation until the patient is clinically sober, and no longer a danger to themselves. Essentially, they're awake and alert with a steady gait.
The main pitfall with alcohol intoxication, is making sure you didn't miss something else. A blood glucose is critical and a good physical exam to make sure you don't see either signs of an alternative diagnosis, or signs of complications of alcohol intoxication, intracranial hemorrhage, fractures, infections, etc.
You ask her to get undressed so you can examine her, she rattles her arm handcuffed to the railing. You help her get mostly undressed, then call the police back in to uncuff her briefly. Her temperature is 98.5 F or 36.9 Celsius, heart rate is 100 bpm, blood pressure is 120/80, respiratory rate 20 and pulse ox 100% on room air. Her speech is slurred. The rest of her exam is completely normal.
She tells you her past medical history is diabetes, she takes metformin for this. You know she was recently out on medical leave. She says she had cellulitis, infection of the skin, resistant to antibiotics requiring several different courses. She says it's healed without complications. She denies other past medical history as well as tobacco and illicit drugs. She doesn’t take supplements, over-the-counter medicines or anything else.
We don't always send labs on intoxicated patients as they are generally not helpful. But in this case, it might be a good idea to cast a wide net. Maybe her sodium is abnormal, or she has sudden onset of renal failure, though this is looking pretty typical for alcohol intoxication rather than a general altered mental status. You ask her if she wants you to send a blood alcohol level to the hospital lab. She shrugs and says I don't care, I didn't drink anything, do whatever you want.
OK, well the situation isn't getting any less awkward, and you have a lot of very sick patients waiting. A few hours later, her labs come back normal, except for the blood alcohol level, which is 100 mg/dL. Uh no.
Let’s discuss blood alcohol levels in more detail. There are two considerations. Medical use and legal use. In the United States a legal blood alcohol level is .08% with the exception of 1 state.
Question 2. Which state has a different legal limit BAL?
A. Montana
B. Louisiana
C. California
D. Utah
Answer: D Utah has a lower limit of 0.05%. These numbers are the legal limit for driving, in general one drink an hour. Some countries have zero tolerance policies where the legal limit is zero. We use different units in the hospital, so a level of 0.08% comes back as a level of 80mg/dL. She’s above the legal limit for driving. As I said, this may not be admissible in court, so the police had their own nurse come to draw a level.
I don’t send a ton of alcohol levels myself. Why? Clinically, they aren't that useful. It doesn’t tell you how “drunk” the patient is because every person has a different metabolism and tolerance. Question #3. Factors affecting metabolism of alcohol include:
A. Red hair color
B. Ethnicity
C. Caffiene
Answer: B ethnicity. Red hair and caffeine consumption don’t change metabolism. Many other things do including genetics, gender, weight, and frequency of alcohol use. As an example, let’s take a level of 400 mg/dL. For most of us, that’s a super high level, I’ve intubated patients who are completely unconscious at this BAL after drinking too much. Conversely, I've had patients in alcohol withdrawal at this level, who are completely awaken alert, shaking, and hallucinating. Meaning their BAL on a daily basis is even higher. Occasionally BAL are useful in pediatrics for example, but even if you find a patient has a high level, it doesn’t rule in or out other problems like medical illness, intracranial hemorrhage, etc.
You stand outside her room, take a few more deep breaths, then enter and ask the officers to leave. You tell her the ethanol level, assuming at this point she might admit to having a few drinks, or at least stop protesting she had none. Wrong, that’s not what happens. She continues to insist she had no drinks at this dinner with a family member.
Well, you’re in charge of the medical part, not the legal part. So whatever the case, her speech is back to normal and she’s ambulatory with a steady gait. You discharge her, unfortunately, in the custody of the police.
As she's walking out of the emergency department, the charge nurse asks, “Do you have to report this?"
A good question and quite frankly one you want nothing to do with. You consider the details. She wasn’t at work. No patients were endangered. You decide no. You don't have a duty to report to the medical board. She may have to, but you don’t.
What about your boss? That's more of a gray zone. You decide your colleague is entitled to privacy as are all our patients. You debate the decision for the rest of your shift, but ultimately conclude it’s the right approach. Relieved the shift is finally ended, you go home and go to bed. Sleep is elusive, you toss and turn all night long.
A few days later, you and the colleague are working the same shift. You spend the first half trying to decide if you should ask her how she's doing and what happened or just proceed as if the incident had never occurred.
The All-Star intern is assigned to your colleagues’ side of the emergency department. When she asks if she can run a case past you quickly, you say no problem, assuming the other attending is busy.
The case is an older man with a sudden onset altered mental status. He was at work as an attorney yesterday. The intern did a big workup, all of which is negative. She wants to know what you’d do next. Admit him to the hospital for further workup, of course. It seems like an obvious answer, but sometimes interns need a reassurance or get a hard time from consultants and want back up. She frowns, says thanks, and you both move on.
A few minutes later loud maniacal laughter rings out from the other side of the ED. It’s your colleague laughing hysterically at the nurse’s station. Seems odd, but laughing is not prohibited in the emergency department. The intern approaches you again an hour later and asks for help. She wants to know if it's inappropriate to ask your colleague to check her own blood sugar. Interns out there, have you ever asked you’re attending to check their own blood sugar? Probably not.
“What?" you say.
“I don't wanna be rude,” she responds, “But I mean, maybe she isn't feeling well and her blood sugar dropped?”
You look over at the nurse’s station. Your colleague is now sitting in a chair, head slumped on her chest. She’s dozed off? In the middle of the loud, brightly lit emergency department?
Oh no.
The poor intern is in a terrible position. She musters her resolve and says “The attending’s management plans today are a bit unusual. She wanted me to send home the attorney with the altered mental status. She told me to order a CAT scan on one patient, but not to do one on another patient with the exact same symptoms. It's really hard to get her attention when I need help.”
Before you can respond, your colleague falls off the chair. The nurses run over to help and scoop her up on a stretcher. The charge nurse looks at you and points to a room. You frantically wave your head no, hoping the intern is not watching, you want to be involved in this even less than the situation a few days ago. The charge nurse ignores you.
The interns eyes widen. “Should I go in to see her?” she asks.
“No. No, definitely not,” you say. “You keep working on your patients. Don't discharge anyone, just do what you think is best and I'll help you as soon as I can.”
“Maybe you’re right about the blood sugar,” you say. Fervently hoping that's the case this time.
It's not.
It’s déjà vu. The situation unfolds the same, except with nursing staff rather than police. You’re colleague is awake, but somnolent, meaning she keeps falling asleep. Her speech is slurred. Her vital signs are completely normal. You order some more basic labs. You order a head CT this time, since she hit her head, but it’s very doubtful this is an intercranial hemorrhage. The nurse holds up the tubes of blood from the IV. “Basic labs. Anything else, doc.” Good question. Should you send a BAL?
This is a conundrum. Do you want to send an alcohol level on someone at work if it won’t change your management? On the other hand, the duty to report here is completely different. She collapsed on the job. If she’s under the influence of drugs or alcohol, she’s endangered patient care. This is a serious issue.
You waiver on the alcohol level and decide to call your boss instead. After a lot of back and forth discussion, you agree to order it. If she does have an alcohol problem, she needs help and can't be allowed to endanger patients. If it’s negative, she needs a much bigger medical work up to find the cause of her altered mental status.
You go back into the room and tell her about the BAL. She tells you to do whatever you want and offers to give a urine for a drug screen as well. She says she doesn't drink alcohol and certainly would never do so at work.
You're in over your head now, seeing your own patients as well as hers. You don't get to back to her for another 3 hours. You open her chart to check the results. Head CT, labs, all negative. Except for her blood alcohol level, it’s 150 mg/dL. Your heart sinks. You really wanted to believe her. Having an alcohol use disorder is one thing. Drinking while seeing patients, you don’t need me to tell you, that’s something else altogether.
She could lose her license. She could lose her entire livelihood. You refresh the screen several times, hoping the number will change to zero, hoping you read it wrong. After a few minutes, you rub your hand through your hair. The only positive thing you can think at this moment is doctors typically do well in drug and alcohol rehab. They tend to be highly motivated, and there’s a lot at stake. There are programs where she can get a second chance, without losing her license, in recovery, encouraging positive consequences from seeking help, rather than only punitive ones.
You go back in the room, she's now awake and alert with clear speech. You tell her the results of the BAL. She adamantly denies drinking, saying you saw me, I was right here at work. Drinking coffee, not alcohol. Go check my thermos. You're not sure how to respond to that, you know, sadly, she’s not the first physician or nurse to drink or do drugs at work.
“Well,” you say, “Are you willing to talk to psychiatry? To get some help?"
“Help with what?”
You have a frustrating, circular conversation with her. On your half, about substance use and psychiatry. On hers, complete denial. At this point there isn’t much you can do. You’ve recommended help, she’s said no. The HR and legal ramifications will move ahead either way. She says she'll take a taxi home. You return to your desk to complete the discharge papers. This is the end of your involvement, but just the beginning for her.
The nurse calls you back saying your colleague wants to speak with you before leaving. You hope she’s changed her mind about psychiatry. She hasn’t. She has a question.
“Could this be auto brewery syndrome,” she asks. You stop in your tracks. Could it be?
Maybe.
What’s auto brewery syndrome? It's a very rare, very unusual disease where a person produces ethanol inside their body. It's called endogenous ethanol production. Endogenous meaning inside. Does she have it? It's a definite zebra, with only about 50 cases published in the medical literature.
She starts crying, saying she doesn't want to lose her job, she's a single mother of a five year old. She sobs, swearing she’d never do anything to endanger her livelihood much less her patients. She’s always been a good colleague who takes good care of her patients. Your brain races at the possibility. After a few seconds, you say, “Obviously I can’t diagnose that here in the ED. I can write in the chart that you consistently deny drinking alcohol, and therefore auto brewery syndrome is a consideration. That way, at least it'll be difficult for any legal action to be taken until it's been further evaluated.”
Doesn't seem like much, but at this moment, it’s about all you can do to help.
Let's talk more about this diagnosis, because it's really fascinating. First question #4.
Everyone produces alcohol.
A. True
B. False
C. You you might be surprised to hear this is true everyone does produce alcohol inside their bodies. It's normally an extremely minuscule amount, in patients with liver disease and diabetes, it’s a tiny bit higher. It’s hard to pinpoint when it was first recognized, but certainly by the 1970s it was noted some patients had elevated ethanol levels without drinking.
How do we know about this? Studies testing blood alcohol levels on thousands of patients without exposure to alcohol. As it turns out the normal BAL isn’t zero like you might guess, but a 0.001%. None of this has any effect on us. Where does it come from? From normal microorganisms in our gut. After you eat, your normal flora produces this tiny amount.
Autobrewery syndrome is when a person produces high levels of endogenous ethanol, enough to be clinically intoxicated and with elevated BALs. How does it happen? Most commonly infection. Often with yeast like Candida or sacronyces cerevisea or Baker's yeast. A few bacteria can do it as well. Essentially you get overgrowth in the gut, called dysbiosis. I'll use the term yeast for the rest of the discussion because that's the most common cause. Yeast are able to convert carbohydrates into ethanol or alcohol. Without yeast, there’s no beer, just carbohydrates like wheat or barley. It’s yeast, saccromyes, that ferments carbs into alcohol. If you have too much of this organism in your gut, the same thing happens when you eat carbs, you get alcohol. It’s absorbed from the gut into the bloodstream, causing intoxication, just as if you had drunk ethanol from a bottle.
Some factors predispose to the development of auto brewery syndrome, antibiotic use is a big one. I'm sure you know antibiotics change your intestinal flora, the reason you get diarrhea. Other risk factors include gastrointestinal problems like gastric bypasses and inflammatory bowel disease like Crohn's or ulcerative colitis, basically reflecting susceptibility to changes in the normal gastric flora. Diabetes and liver disease may be contributory as well.
What symptoms does autobrewrey syndrome cause? Simple, intoxication. Ie the person is drunk. BALs can range anywhere from 20 mg/dL or .02, up to 400mg/dL or .4! A level of 400 is extremely high unless you're chronically exposed to alcohol. Patients are at risk for all the complications of intoxication falls, fractures, intracranial hemorrhages, seizures. A man and his wife thought that he was developing dementia because he became so forgetful with memory loss. They're at risk for complications of chronic alcohol exposure, including depression, bizarre behavior, frequent, unexplained hangovers.
How do you diagnose it? That’s the difficult part. Most patients have symptoms for months, more like years before it's diagnosed. Essentially it consists of checking blood alcohol levels at baseline then again at hours 2, 4, 6, 8, 16 and 24 hours It has to be done under observation to ensure there’s no exogenous alcohol, ie drinks, involved. Generally meaning hospital admission. Why the prolonged testing? Some yeast are very slow to convert carbohydrates to ethanol. Once you establish endogenous production, you then need to find the source, meaning the yeast or bacteria responsible. Urine and stool testing is necessary. Often patients require endoscopy and colonoscopy to take biopsies for further investigation.
There are two unusual cases with this already unusual disease.
Question # 5. Where else can bacterial overgrowth occur in auto brewery syndrome?
A. Bladder
B. Brain
C. Heart
Answer: A. Bladder .
In one case, a patient had an infection in their bladder, producing ethanol. In another patient with very poor oral hygiene, it was coming from microorganisms in their mouth. Yikes.
Once you diagnosis it, is it treatable? Yes. First patients are advised to eat low carbohydrate diets. Basically, ethanol can’t be produced without carbs. There are clear reports of exacerbation of symptoms after a high carb meal, for example in one patient after pizza and beer.
Also, antifungals for yeast or antibiotics for bacteria depending on the cause. Weeks of treatment is often required with a slow taper, to make sure the overgrowth doesn’t come back. Some have suggested probiotics, though it’s unclear if these help. In addition, patient are advised to check their blood alcohol daily with a breathalyzer test. For safety reasons, it also helps determine if the antimicrobial treatment is working, and if the taper is too fast, etc.
The last option is a fecal transplant. Which can be effective and is about as crazy as it sounds. These are most often used to treat refractory C.diff infections. It’s taking stool from a person with healthy gut flora and transplanting it via colonoscopy or pills into the person with auto brewery syndrome.
Now let's talk a little bit about the legal aspect of this, and just to be clear I'm a doctor not a lawyer. But it does raise interesting questions I think are worth discussing. I'm wondering if this is every attorney's favorite medical diagnosis. If you're an attorney and you have a different favorite, let me know, I’d love to hear what it is. As you can imagine patients have legitimately use this as a defense after DUI. On the other hand, I'm sure there are people who’d like to use it as a defense after exogenous alcohol ingestion. How can we tell the difference? We can’t that’s why it’s a legal gray zone. Anyone with auto brewery syndrome can go out for drinks and have a legitimate DUI as well as vice versa. I like the ruling of a judge in Belgium, it seems pretty fair. The man worked at a brewery and had several DUIs. He was diagnosed with auto brewery syndrome, so the judge acquitted him of the DUI charges. However, he told the man he either had to stick to a low-carb diet or install an auto lock on his car. Like a breathalyzer test before the car will start, telling them that if he ever get another DUI that the man would be convicted.
Obviously, it’s not the man's fault that he has this disease, but it doesn't change the fact that driving while intoxicated carries the same risks regardless of the source of the alcohol. So I think a breathalyzer test before driving ensures the safety of the patient as well as everyone else on the road. From a medical standpoint, patients are advised to take breathalyzers prior to swimming or operating heavy machinery for safety.
So back to your colleague. She’s suspended from work, so you don't see her for a a while. Six months later, she’s back on a shift. She runs up and gives you a big hug, thanking you for writing about auto brewery in her chart. She had an extensive work up with gastroenterology, including endoscopy, colonoscopy, biopsies and cultures. She has autobrewey syndrome due to candida overgrowth after the prolonged course of antibiotics she took for cellulitis. As a result, she didn’t have any legal issues or problems maintaining her medical license.
You apologize for being skeptical, doubting her. She shrugs and smiles saying I would've done the same if our situations were reversed. She thinks her symptoms are gone after nearly a month on antifungals. She holds up a breathalyzer machine, to test herself before driving and before every shift. This case is fictional as are all our cases to protect the innocent. It is based on real cases.
Last question in today’s podcast. We talked about how yeast causes auto brewery syndrome and also necessary to ferment grain into beer. Definitive evidence of beer brewing is found first found in which culture?
A. Mesopotamia
B. Egypt
C. Greek
Follow the Twitter and Instagram feeds both @pickpoison1 for the answer. Remember, never try anything on this podcast at home or anywhere else.
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While I’m a real doctor this podcast is fictional, meant for entertainment and educational purposes, not medical advice. If you have a medical problem, please see your primary care practitioner. Until next time, take care and stay safe.