A 46-year-old man is admitted to the hospital for atypical chest pain. His medical history is significant for hypertension controlled with amlodipine and hypercholesterolemia treated with atorvastatin; he has a family history of depression and heart disease. During review of his substance use history, the patient says that he has been a "regular drinker" for the last 5 years. He drinks a 6-pack of beer every night and has 2 more beers in the morning to help him "get through the day." He also admits to smoking marijuana occasionally but does not use tobacco or other illicit drugs. Which of the following symptoms or signs is most likely to appear earliest during this patient's hospitalization?
Alcohol withdrawal syndrome | ||
Manifestations | Symptoms/signs | Onset since last |
Mild | Anxiety, insomnia, tremors, diaphoresis, palpitations, gastrointestinal upset, intact orientation | 6-24 |
Seizures | Single or multiple generalized tonic-clonic | 12-48 |
Alcoholic | Visual, auditory, or tactile; intact orientation; stable vital signs | 12-48 |
Delirium | Confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations | 48-96 |
Ethanol use leads to a number of biochemical changes in the CNS. It acutely potentiates the effects of GABA (the primary inhibitory neurotransmitter in the CNS) at GABA-A receptors, leading to sedation. Chronic ethanol use causes downregulation of GABA receptors. Alcohol also weakly inhibits excitatory NMDA receptors in the brain, and chronic exposure leads to upregulation of these receptors. These adaptive changes result in tolerance (ie, the need to increase the dose to achieve the desirable effect) and symptoms of withdrawal on abrupt alcohol cessation, a common occurrence during hospital admission. Both tolerance and withdrawal are signs of substance dependence.
Withdrawal symptoms can begin as early as 6 hours after the patient's last drink, typically reach maximal intensity in 2-3 days, and subside in 4-5 days if the withdrawal is not severe. Tremor, or "the shakes," is the most common initial finding. Patients also typically have signs of mild autonomic dysfunction (eg, increased heart rate and respirations), gastrointestinal distress (eg, nausea, vomiting), and anxiety.
(Choice A) Fluctuating arousal levels are characteristic of delirium tremens, a potentially fatal manifestation of alcohol withdrawal that typically begins 48-96 hours after the last drink. Other findings include sympathetic hyperactivity (eg, hyperthermia, hypertension), hallucinations (eg, visual, auditory, and/or tactile), and confusion.
(Choices B and C) Hypersomnolence and nystagmus can occur in acute ethanol intoxication but are not common during alcohol withdrawal. Most patients have insomnia attributable to increased CNS excitability during the withdrawal period.
(Choice D) Tonic-clonic seizures can occur 12-48 hours after the last drink and affect <5% of patients undergoing alcohol withdrawal.
(Choice F) Alcoholic hallucinosis (ie, visual hallucinations) can develop within 12-48 hours after the last drink. These early hallucinations are distinct from delirium tremens.
Educational objective:
Tremulousness is typically one of the earliest symptoms of alcohol withdrawal. Other common symptoms include gastrointestinal distress, agitation, anxiety, and autonomic disturbance. Delirium tremens is the most severe manifestation of alcohol withdrawal and typically begins 48-96 hours after the last drink.