[jMyles]

Second and third paragraphs under "discussion":

> Auto-brewery syndrome is thought to result when microorganisms capable of fermenting alcohol from carbohydrates outgrow normal gut flora.6 Although population-based studies have shown that gut alcohol fermentation with low levels of endogenous ethanol can occur even among healthy people, blood ethanol levels rarely reach concentrations high enough to cause intoxication.7 Auto-brewery syndrome is uncommon because it requires several host factors to interact with substantial overpopulation of fermenting microorganisms, and high carbohydrate consumption.6 Comorbidities such as diabetes, liver disease, gut dysmotility disorders, and inflammatory bowel disease are associated with auto-brewery syndrome through mechanisms contributing to increased levels of blood glucose and decreased ethanol metabolism.6,7 Genetic predisposition for inactive aldehyde dehydrogenase enzyme and subsequent inefficient alcohol metabolism, may also play a role.6 In our patient, we suspect her recurrent antibiotics for UTI and dexlansoprazole use led to gut dysbiosis with potential contribution of genetics, resulting in auto-brewery syndrome.

> Commonly implicated fungi responsible for outgrowing normal gut flora in auto-brewery syndrome are Saccharomyces cerevisiae and Candida species including C. albicans, C. tropicalis, and C. glabrata.2 Bacteria have also been cultured from patients with auto-brewery syndrome. Although the role of bacteria remains unclear, a recent case–control study proposed Klebsiella pneumoniae as an important culprit.7–9