Review Question - QID 217043

This patient who initially presented with somnolence, slurred speech, and nystagmus with an elevated serum osmolal gap likely had ethanol intoxication in the setting of chronic alcohol abuse. His new symptoms of altered mental status, agitation, fever, hypertension, tachycardia, and diaphoresis 3 days after discharge to a temporary housing facility are likely due to a severe form of alcohol withdrawal known as delirium tremens.

Delirium tremens classically presents with delirium, agitation, fever, hypertension, tachycardia, and diaphoresis between 48 and 96 hours after the last alcoholic drink. Patients are also often hypovolemic, hypokalemic, hypomagnesemic, and/or hypophosphatemic. Risk factors for developing delirium tremens include chronic alcohol abuse and a history of alcohol withdrawal seizures. Because delirium tremens can be life-threatening, patients require early diagnosis and admission for close monitoring. Treatment is with intravenous benzodiazepines (e.g., diazepam, lorazepam).

Schuckit reviews the management of delirium tremens. The author provides a suggested treatment algorithm for delirium tremens that includes admission to the intensive care unit if possible, frequent monitoring of vital signs, administration of thiamine to prevent Wernicke encephalopathy, and benzodiazepine administration.

Incorrect Answers:
Answer 1: Alcoholic hallucinosis presents with visual, auditory, and/or tactile hallucinations between 12 and 48 hours after the last alcoholic drink. Patients are typically oriented and have normal vital signs.

Answer 2: Bacterial meningitis can present with fever, tachycardia, and altered mental status but signs of meningeal irritation would be expected, such as nuchal rigidity. Additionally, patients with severe bacterial infections tend to be hypotensive as opposed to hypertensive.

Answer 3: Brief psychotic disorder is on the spectrum of psychotic disorders along with schizophrenia and is characterized by delusions, hallucinations, disorganized speech, and/or grossly disorganized behavior that remit within 1 month. Vital sign abnormalities would not be present.

Answer 5: Serotonin syndrome can present with altered mental status and vital sign instability including hyperthermia, hypertension, tachycardia, and diaphoresis in the setting of serotonergic drug use (e.g., selective serotonin reuptake inhibitors). However, hyperreflexia and clonus are hallmarks of this disorder.

Bullet Summary:
Delirium tremens is a severe form of alcohol withdrawal characterized by altered mental status, fever, tachycardia, hypertension, and diaphoresis that occurs within 48-96 hours after the last alcoholic drink.