A 34-year-old man is brought to the emergency department due to confusion. The patient recently lost his job and moved in with his parents yesterday because he could no longer afford housing. Today, his mother found him disoriented and unsteady. He has no known chronic medical conditions and takes no medications. Temperature is 38.5 C (101.3 F), blood pressure is 164/90 mm Hg, pulse is 108/min, and respirations are 22/min. The patient appears restless and is constantly picking at the bed linens, yelling, "Get these bugs off me." The lungs are clear on auscultation, and cardiac examination is unremarkable with the exception of regular tachycardia. The abdomen is soft and nontender. No extremity edema is present. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 14.8 g/dL |
| Mean corpuscular volume | 104 µm3 |
| Platelets | 300,000/mm3 |
| Leukocytes | 11,000/mm3 |
| Serum chemistry | |
| Sodium | 146 mEq/L |
| Potassium | 3.1 mEq/L |
| Magnesium | 1.8 mg/dL |
| Phosphorus | 2.4 mg/dL |
| Creatinine | 0.8 mg/dL |
Which of the following would be most helpful to improve this patient's current condition?
This patient's acute confusion, disequilibrium, restlessness, and visual/tactile hallucinations raise strong suspicion for alcohol withdrawal. Although ~14% of people in the United States have alcohol use disorder, it is often masked until alcohol intake is abruptly reduced or stopped, as likely occurred when this patient changed his living situation from living alone to living with his parents.
Alcohol is a strong CNS depressant that enhances GABA (inhibitory) signaling and reduces NMDA (excitatory) signaling. Most patients with alcohol use disorder develop a new homeostasis whereby the depressant effects of alcohol are required to counterbalance innate CNS excitatory signaling; therefore, reduced alcohol consumption can result in rebound CNS overexcitation.
Manifestations usually begin 6-24 hours after alcohol cessation and include anxiety, agitation, tremor, diaphoresis, and nausea. More severe cases are marked by ≥1 of the following:
Alcohol withdrawal is treated primarily with benzodiazepines. This class of medications activates the GABA A receptor, which dampens excitatory signaling and somewhat replaces the effect of alcohol. Long-acting benzodiazepenes (eg, chlordiazepoxide) help reduce the rate of recurrent withdrawal or seizures, leading to a smoother clinical course. Significant electrolyte abnormalities and dehydration are also often present, so electrolyte and fluid replacement is generally required.
(Choice A) Atypical antipsychotic agents treat a wide range of psychoses, including schizophrenia. Although visual hallucinations are often present, this patient's concomitant autonomic instability, electrolyte abnormalities, and macrocytosis make alcohol withdrawal more likely.
(Choice B) Acute bacterial infection with sepsis can cause delirium, fever, and sinus tachycardia. However, visual hallucinations would be atypical. In addition, significant leukocytosis is generally present.
(Choice D) Hypothyroidism can cause delirium and hypertension, but fever, tachycardia, and visual hallucinations would be atypical.
(Choice E) Thiamine deficiency is common in patients with alcohol use disorder. It can cause Wernicke encephalopathy, which is associated with delirium, ataxia, and oculomotor dysfunction. However, autonomic instability and visual hallucinations are atypical.
Educational objective:
Patients with alcohol use disorder are at risk for alcohol withdrawal with alcohol reduction/cessation. Manifestations begin within 6-24 hours and include anxiety, agitation, tremor, diaphoresis, and nausea. More severe cases are marked by delirium tremens (eg, autonomic instability, delirium), hallucinations, and/or seizures. The primary treatment is with benzodiazepines, which dampen CNS excitation.