Table 1

Summary of events

Approximated time	Event	Result/response
January 2011	A 46-year-old man from North Carolina with traumatic thumb injury treated with cephalexin 250 mg for 3 weeks.	Mental status changes, brain fog, and depression (commonly after meals)
January 2014	Seen a psychiatrist for the first time and began treatment with lorazepam and fluoxetine.	Partial improvement
March 2014	Hospitalised after DWI*, patient denied any alcohol ingestion.	BAC elevated (200 mg/dL)
March 2014	Began self-monitoring his BAL using a breathalyser.	Intermittently positive without any alcohol intake.
March 2015	Travelled to Ohio seeking treatment.
May 2015	Stool testing performed.	Saccharomycescerevisiae (brewer’s yeast)
September 2015	A carbohydrate challenge meal (50 g) was given and alcohol levels were measured while under complete observation.	Blood alcohol level was increased to 57 mg/dL in 8 hours.
September 2015	Started on a carbohydrate-free diet with fluconazole 150 mg per day. It was later changed to nystatin 50 000 IU due to lack of effect.	Mental status slightly improved but brain fog returned in a few weeks.
September 2015	Continued to seek further treatment and he consulted multiple physicians over 2 years.	No significant clinical improvement.
February 2017	Patient hospitalised again for intracranial bleeding after a fall while inebriated.	Inpatient BAC fluctuated 50–400 mg/dL during this entire time.
September 2017	He travelled to New York seeking further management due to recurrent symptomatic flares.
September 2017	Upper and lower endoscopy were performed and gastrointestinal secretions were collected.	C.albicans and C.parapsilosis were detected.
September 2017	Started on daily itraconazole 150 mg (later increased to 200 mg) while continuing a carbohydrate-free diet.	Became completely asymptomatic.
October 2017	While on treatment, he consumed pizza and soda.	Severe relapse of ABS requiring hospitalisation once again.
January 2018	A peripherally inserted central catheter was inserted and started on micafungin 150 mg per day for 6 weeks.	Complete resolution of symptoms.
February 2018	After completion of antifungal therapy, a repeat study of gastrointestinal secretions via endoscopy was done.	No fungal growth detected.
February 2018	Provocative carbohydrate challenge test performed.	Breathalysers and blood alcohol levels both became negative.
May 2019	Patient was being followed by his primary care physician while gradually reintroducing carbohydrates to his diet.	He remains asymptomatic on a normal diet for about 1.5 years.

*Legal DWI concentration limit=0.08% or 8 mg/dL.
ABS, auto-brewery syndrome; BAC, blood alcohol concentration; BAL, breath alcohol level; C. albicans, Candida albicans; C. parapsilosis, Candida parapsilosis; DWI, driving while intoxicated.