A Rare Diagnosis of Gut Fermentation/Auto-Brewery Syndrome in the Setting of Diabetes and Obesity

Abstract

<2%. The tumor cells stained positive for desmin and negative for S100, CD117, ERG, and HHV8. The in situ hybridization (ISH) for EBV showed positive staining on the tumor cells and also in the infiltrating lymphocytes. Results: The patient's history of treated retroperitoneal and liver leiomyosarcoma raises a suspicion of recurrence of a similar pattern of smooth muscle neoplasm. Detection of EBV in tumor cells by in situ hybridization differentiates the diagnosis of EBV-associated SMN from conventional leiomyoma/leiomyosarcoma. Conclusion: The most common EBV-associated SMT is human immunodeficient virus associated (HIV-SMN). HIV-SMN shows a variable histology like leiomyoma to leiomyosarcoma. Positive staining for EBV-encoded small RNA in situ hybridization is crucial to distinguish the EBV-SMN from others. Introduction: Gut fermentation or auto-brewery syndrome is a relatively uncommon medical condition that presents a diagnostic and therapeutic challenge. Case Report: Here we present a unique case of a 45-year-old obese, male, diabetic patient treated with two courses of antibiotics for deviated nasal septum and dental procedure who reported episodes of diarrhea, vomiting , edema, seizures, hallucinations, intermittent fevers, chills, slurred speech, and loss of consciousness precipitated after meals for a duration of 14 months. The patient denied alcohol consumption at any time. His blood etha-nol levels, measured on multiple occasions, were elevated and corroborated by a 24-hour meal test administered in the hospital. Small bowel and fecal contents collected during the endoscopic procedures were remarkable for the growth of Saccharomyces cerevisiae from both samples. Gram stain was negative for Salmonella, Shigella, or Campylobacter. A rapid membrane enzyme immuno-assay for C difficile antigen and toxins A and B was also negative. The patient responded well to oral fluconazole but relapsed after a month and needed further assessment. Microbiological studies undertaken on gastric and small bowel contents collected during the follow-up upper and lower endoscopic procedures were positive for Candida intermedia, sensitive to fluconazole (0.250 mcg/ mL) and amphotericin B (0.250 mcg/mL). Bacterial cultures showed rare, positive growth for Klebsiella pneumo-niae and Enterococcus faecium. The patient responded dramatically to a no-carbohydrate diet and intravenous administration of an antifungal agent through a