Seeing insects on the wall 40 hours after his last drink
A 46-year-old man is brought to the emergency department by his brother at 03:00. He has drunk at least half a litre of vodka daily for many years and his last drink was about 40 hours ago. For the past 10 hours he has been sweating, shaking, and seeing small insects on the wall; tonight he did not recognise his brother and tried to climb out of a window. He had a withdrawal seizure during a previous admission. Temperature 38.0 °C, pulse 122/min, blood pressure 158/96 mmHg, respiratory rate 22/min, oxygen saturation 96% on room air; he is tremulous, disoriented to time and place, with a coarse tremor of both hands, no focal neurological signs, no neck stiffness and no rash. Capillary glucose 118 mg/dL, sodium 134 mEq/L, potassium 3.1 mEq/L, magnesium 1.4 mg/dL, creatinine 1.1 mg/dL, ALT 88 U/L, platelets 132,000/mm3. A urine drug screen is negative and blood alcohol is 0.
1. What is the diagnosis, and how do you distinguish it from two conditions that look similar?
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Diagnosis: delirium tremens (alcohol withdrawal delirium), supported by heavy daily drinking, onset about 40 hours after the last drink, clouded consciousness with disorientation, visual hallucinations, coarse tremor, autonomic hyperactivity (pulse 122, blood pressure 158/96, temperature 38.0 °C, sweating) and a previous withdrawal seizure, which marks him as a high-risk patient.
Distinguish from alcohol hallucinosis: in hallucinosis the sensorium is clear, the patient is oriented, autonomic overactivity is mild or absent, and symptoms usually begin within 12-24 hours of the last drink and resolve in a day or two. This man is disoriented, does not recognise his brother and is tachycardic and hypertensive, which puts him in the delirium group. The distinction matters because hallucinosis may need only observation and a modest benzodiazepine course, whereas delirium tremens is potentially fatal and needs admission.
Distinguish from a primary psychotic disorder or stimulant intoxication: neither produces a coarse tremor, fever, tachycardia and clouding of consciousness in this temporal pattern, and his urine drug screen is negative. Repeated hallucinations without autonomic signs and with intact insight would point elsewhere.
Third, do not miss another cause of delirium: hypoglycaemia (glucose 118), head injury or subdural haematoma (no focal signs, but consider imaging if any trauma or persisting confusion), meningitis (no neck stiffness, but fever is present), electrolyte disturbance (corrected below), hepatic encephalopathy and infection such as pneumonia or urinary tract infection. Delirium is a syndrome, so keep looking for a second cause.
2. Write your acute management: drugs with doses and route, monitoring, and one class you must not use as monotherapy.
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Benzodiazepines, symptom-triggered with the CIWA-Ar scale, are the treatment of choice. Give diazepam 10-20 mg orally or intravenously every 1-2 hours until he is calm, awake and follows simple commands, then taper; or chlordiazepoxide 25-50 mg orally. If liver disease is more advanced than the ALT suggests, use lorazepam 2-4 mg (it is glucuronidated and safer in hepatic impairment). Reassess CIWA-Ar and vital signs every 1-2 hours and chart the cumulative dose. Do not use a fixed large dose and leave him unmonitored.
Thiamine 100 mg intravenously before any glucose, then 100 mg daily for at least 3-5 days, plus folate and a multivitamin, to prevent Wernicke encephalopathy and Korsakoff syndrome.
Fluids and electrolytes: intravenous normal saline with potassium replacement for K 3.1, and magnesium replacement for Mg 1.4, because hypomagnesaemia makes the hypokalaemia refractory and predisposes to arrhythmia. Recheck at 6 and 12 hours.
Environment: a quiet, well-lit side room with one-to-one nursing, repeated reorientation, and avoidance of physical restraint where possible.
Do not use antipsychotics such as haloperidol as monotherapy: they lower the seizure threshold, do not treat the underlying withdrawal, mask autonomic instability and impair thermoregulation. A low dose may be added only as an adjunct for persistent hallucinations once benzodiazepines have been given adequately. Avoid beta-blockers as the main treatment for the same reason, since they hide the signs used to titrate therapy.
3. He is stable after 24 hours. What else must be done before discharge, and what complication of repeated withdrawal should you warn him about?
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Medical work-up: screen for the consequences of chronic alcohol use, which affect the discharge plan as much as the withdrawal itself: full blood count and mean corpuscular volume, liver enzymes and clotting, renal function, magnesium, phosphate, thiamine, hepatitis B and C and HIV serology, chest radiograph, and consideration of ultrasound for fatty liver or cirrhosis. Consider pancreatitis if there is abdominal pain, and screen for tuberculosis and for injection-related infection where relevant.
Psychiatric assessment: ask directly about suicidal ideation and assess for depression or anxiety, which are common and undertreated in this group. A urine drug screen is already negative, but re-screen if the history suggests polysubstance use.
Discharge plan: a structured benzodiazepine taper over about 5-7 days, continued thiamine and vitamins, a clear plan for the first 72 hours, referral to addiction treatment with a key worker, and involvement of the brother with the patient consenting to share information. Book an early follow-up appointment rather than telling him to return if needed.
Warn him about kindling: each repeated withdrawal episode is worse than the last, with a lower threshold for seizures and delirium, because of progressive sensitisation of the central nervous system. His previous withdrawal seizure is the clinical evidence of this. This is why abrupt unsupervised cessation is dangerous and why medically supervised detoxification is the safer route for the next attempt.