High Urine Ethanol and Negative Blood and Vitreous Ethanol in a Diabetic Woman

Abstract

Several studies have shown that ethanol can be produced in urine infected with yeast or bacteria in vitro. We present the unusual case of a diabetic woman in whom ethanol was produced in her urine in vivo. The decedent was a 19-year-old woman who was noncompliant with her diabetes treatment. She presented to a local hospital in severe diabetic ketoacidosis and died shortly thereafter. Upon arrival at the hospital, a blood glucose of 553 mg/dL was detected. A urinalysis was positive for ketones (> 80 mg/dL), glucose (> 1000 mg/dL), and large budding yeast forms. A drug screen performed on the urine was positive for ethanol. At the coroner/medical examiner office, an autopsy was negative for significant anatomic findings. Toxicology analysis revealed a urine ethanol level 0.32 g/dL, although no ethanol was detected in blood or vitreous samples. A urine gram stain and culture identified Candida glabrata. A retrospective case review of all deaths related to diabetes examined at the coroner/medical examiner office from 1986 to 2003 did not reveal other cases with similar findings. This case of a noncompliant, juvenile-diabetic woman illustrates a rare finding of apparent in vivo glucose fermentation by C. glabrata to form ethanol in the urine. This case also highlights a potential difficulty in toxicologic analysis and interpretation using urine only.

Gut and bladder fermentation syndromes: a narrative review

“…These predictions fit with the previous literature, including our case report [ 2 ]. In a previous forensic case report, C. glabrata was also identified as the causative yeast for fermentation in the urine specimen [ 4 ], and the authors suspected a pathophysiology equivalent to BFS.…”

“…This short report recommends standardized testing for glucose in the urine and adding fermentation inhibitors such as sodium or potassium fluoride to the patient’s urine samples before specimen processing and measuring ethanol levels [ 5 ]. Presumed BFS has also been reported in post-mortem studies in forensic journals, the common denominator in all of these cases being patients with poorly controlled diabetes [ 4 ].…”

“…Ethanol production by fermenting yeast and bacteria was reported in a urine specimen in vitro, as summarized by Gruszecki et al [ 4 ], especially if the specimen tube is left outside the refrigerator. One forensic report described in vitro ethanol production by fermentation in the urine specimen of diabetic rape victims.…”

“…The victims were falsely suspected of being intoxicated at the time of sexual assault because of high ethanol levels in their urine specimens [ 5 ]. In another forensic report, the authors retrospectively speculated that fermentation began in the bladder of a patient before death [ 4 ]. Integrating these previous cases, it is reasonable to conclude that fermentation occurs in the bladder where a patient is infected with or colonized by fermenting yeast with access to sugar.…”