A 61-year-old woman was almost rejected for a liver transplant after tests showed alcohol in her urine. Turns out, her bladder was actually brewing alcohol.
The woman, who wound up in a case report published in the Annals of Internal Medicine, went to the University of Pittsburgh Medical Center (UPMC) for a liver transplant. She had been rejected from another hospital after her urine tested positive for alcohol, and UPMC also wouldn’t add her to their waiting list. Instead, she was referred to a treatment program for alcohol addiction instead.
The woman, who had uncontrolled diabetes, repeatedly denied drinking alcohol and didn’t seem to be drunk. Eventually, doctors decided to look at her lab results again.
That’s when they noticed that her urine tests for two metabolites of alcohol, ethyl glucuronide and ethyl sulfate, were negative (at least one of them should be in her urine for several days if she had alcohol). Her blood tests were negative for alcohol as well. Doctors also noticed that she had high levels of sugar in her urine, due to her poorly controlled diabetes, as well as high levels of yeast. Eventually, they realized the woman’s bladder was fermenting the sugar in her body into alcohol—a condition known as bladder fermentation syndrome or auto-brewery syndrome. (This is the first proven clinical case of auto-brewery syndrome happening in the bladder. It typically occurs in the gut.)
Auto-brewery syndrome is rare, but not so rare that doctors don’t consider it when a patient says that they haven’t been drinking but medical tests suggest otherwise. “We considered it for one of our patients who insisted he hadn’t been drinking,” says Kathryn A. Boling, M.D., a primary care physician at Baltimore’s Mercy Medical Center.
So, the doctors in the case report decided to try an experiment. They got a new urine sample from the patient and let it sit in their lab for 24 hours at different temperatures. When it was at 98.6 degrees, the alcohol level increased by 18 times, indicating that the yeast in the woman’s pee was converting the sugar in her body into alcohol. Not only that, the type of yeast in her body (Candida glabrata) is similar to brewer’s yeast (Saccharomyces cerevisiae) which is used to make alcohol.
The exact mechanism can vary by person and where in the body auto-brewery syndrome is taking place. But “sometimes there’s enough stuff in the intestinal tract or bladder that combines and starts to ferment,” Dr. Boling explains. People who have diabetes are more likely to have yeast in their body, and that can “grow like crazy in a sugary environment.”
“Sometimes, in your urine, you have elevated levels of ketones, which happen when you are not able to process sugars. That can be excreted in the urine,” explains Shilajit D. Kundu, M.D., an associate professor of urology at Northwestern Medicine. “Certain bacteria in the urine or yeast can process sugars in a way that creates alcohol.”
Study co-author Kenichi Tamama, M.D., Ph.D., an associate professor of pathology at the University of Pittsburgh School of Medicine, says the findings of this case report are especially important for clinicians who monitor alcohol abstinence. “Once the diagnosis of an alcohol use disorder is attached to the patient, the assumption of surreptitious alcohol use can haunt and falsely stigmatize the patient,” he says.
Ultimately, the woman was reconsidered for her liver transplant.