Psychiatry · Moderate
This case is fictional and exists for study. It describes no real patient.
52 years · male
A 52-year-old male is brought to the emergency department by his partner due to severe agitation and confusion. His partner reports that he abruptly stopped drinking alcohol 3 days ago after heavily consuming approximately 20 units of spirits daily for several years. Over the last 12 hours, he has become increasingly restless, excessively sweaty, and claims to see insects crawling on the walls. He has no past medical history of psychiatric illness or seizures. On examination, he is disoriented to time and place, marked by a prominent coarse tremor in both hands and visible diaphoresis. Physical examination reveals no focal neurological deficits, and abdominal examination is unremarkable.
Vital signs
- HR
- 118 bpm
- BP
- 158/96 mmHg
- RR
- 22/min
- Temp
- 37.9 °C
- SpO₂
- 97%
Examination findings
- Coarse bilateral tremor of the hands
- Profuse diaphoresis
- Visual hallucinations and disorientation to time and place
Investigations
| MCV | 102 fL | reference: 80-100 |
| GGT | 148 U/L | reference: <50 |
| Serum Sodium | 138 mmol/L | reference: 135-145 |
| Serum Potassium | 3.7 mmol/L | reference: 3.5-5.0 |
Question 1 of 3
Which of the following is the most likely diagnosis?
The clinical picture of onset 48-96 hours after alcohol cessation, clouding of consciousness (disorientation), visual hallucinations, severe tremor, and autonomic instability (tachycardia, hypertension, fever) is classic for delirium tremens. Alcoholic hallucinosis occurs within 12-24 hours with visual/auditory hallucinations in clear consciousness and normal vitals. Wernicke's encephalopathy presents with the classic triad of ophthalmoplegia, ataxia, and confusion, without pronounced autonomic hyperarousal. Schizophrenia-related acute psychosis typically lacks acute autonomic overdrive and a clear temporal relationship with alcohol withdrawal.
Teaching point: Delirium tremens onset occurs 48–96 hours after alcohol cessation and is distinguished from alcoholic hallucinosis by altered consciousness and severe autonomic instability.
Question 2 of 3
Which of the following is the most appropriate initial medical management for this patient's presentation?
Benzodiazepines (e.g., diazepam or chlordiazepoxide) are the first-line medical intervention for severe alcohol withdrawal and delirium tremens to reduce central nervous system irritability, suppress autonomic hyperactivity, and prevent seizures. Haloperidol monotherapy is inappropriate because antipsychotics lower the seizure threshold and do not treat the underlying GABA withdrawal. Acamprosate is used for relapse prevention in abstinent individuals, not acute withdrawal. Phenytoin is ineffective for alcohol withdrawal-induced seizures.
Teaching point: Benzodiazepines are first-line in acute alcohol withdrawal: NICE recommends oral lorazepam for delirium tremens, and long-acting chlordiazepoxide or diazepam for uncomplicated withdrawal, with shorter-acting agents preferred in liver impairment.
Question 3 of 3
To prevent the precipitation of Wernicke's encephalopathy, which action must be performed prior to administering intravenous carbohydrate solutions in this patient?
Parenteral thiamine (vitamin B1) must always be given before or alongside any carbohydrate/glucose administration in patients with chronic alcohol dependency. Glucose oxidation rapidly exhausts remaining thiamine stores, which can directly precipitate acute Wernicke's encephalopathy. Folate and pyridoxine address nutritional deficiencies but do not prevent Wernicke's encephalopathy. While magnesium is a cofactor for thiamine-dependent enzymes, parenteral thiamine is the mandatory, primary step.
Teaching point: Always give parenteral thiamine prior to or concurrently with carbohydrate infusions in patients with alcohol dependency to prevent precipitating Wernicke's encephalopathy.
Key learning points
- Delirium tremens typically manifests 48-96 hours after stopping alcohol and is characterized by confusion, hallucinations, and autonomic hyperactivity.
- Benzodiazepines (e.g., diazepam or chlordiazepoxide) are the definitive first-line pharmacological treatment for acute alcohol withdrawal.
- Parenteral thiamine must be administered before or alongside glucose infusions to prevent Wernicke's encephalopathy.
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