Delirium Tremens: Assessment and Management

Hepatic encephalopathy: a neurologist's perspective

Liver disease is increasingly common, estimated to affect over 25% of the world's population. Failure of the liver to maintain a normal metabolic milieu leads to impaired brain function (hepatic encephalopathy), and conditions that cause liver disease can themselves predispose to neurological disease. As neurologists' involvement with the acute take increases, it is important that we are familiar with the neurological complications of liver disease, their investigation and management, and to know which other neurological diseases occur in this patient population. In this article, we review the causes, presentation and treatment of hepatic encephalopathy, and discuss important differential diagnoses in patients with liver disease who present with neurological disturbance.

Delirium Tremens: A Review of Clinical Studies

Delirium tremens (DT) is a severe condition resulting from alcohol withdrawal. This review highlights the challenges in diagnosing and managing DT and emphasizes the importance of early recognition and intervention to prevent complications and ensure optimal patient outcomes. The discussion of the pathophysiology of DT, focusing on the neurochemical imbalances involving the neurotransmitters gamma-aminobutyric acid and glutamate, explains how chronic alcohol dependence leads to these imbalances and contributes to the hyperexcitability seen in DT. The management of DT involves ensuring patient safety and alleviating symptoms, primarily through pharmacological approaches, such as benzodiazepines. Closely monitoring vital signs and electrolyte imbalances is necessary due to autonomic dysregulation associated with DT. The mention of the potential complexity of DT when coexisting with other conditions emphasizes the need for additional research to advance comprehension, identify predictive factors, and enhance its management.

GABAergic mechanisms in alcohol dependence

The target of alcohol's effect on the central nervous system has been sought for more than 50 years in the brain's GABA system. The behavioral and emotional effects of alcohol in humans and rodents are very similar to those of barbiturates and benzodiazepines, and GABAA receptors have been shown to be one of the sites of alcohol action. The mechanisms of GABAergic inhibition have been a hotspot of research but have turned out to be complex and controversial. Genetics support the involvement of some GABAA receptor subunits in the development of alcohol dependence and in alcohol use disorders (AUD). Since the effect of alcohol on the GABAA system resembles that of a GABAergic positive modulator, it may be possible to develop GABAergic drug treatments that could substitute for alcohol. The adaptation mechanisms of the GABA system and the plasticity of the brain are a big challenge for drug development: the drugs that act on GABAA receptors developed so far also may cause adaptation and development of additional addiction. Human polymorphisms should be studied further to get insight about how they affect receptor function, expression or other factors to make reasonable predictions/hypotheses about what non-addictive interventions would help in alcohol dependence and AUD.

Successful treatment of severe alcohol withdrawal delirium with very high-dose diazepam (260-480 mg) administration

INTRODUCTION

Alcohol withdrawal delirium, commonly known as "delirium tremens (DT)", is the most severe clinical condition of alcohol withdrawal syndrome (AWS). Symptoms of DT include changes in consciousness and cognitive and perceptual impairments that fluctuate during the day. Treatment includes general support, such as helping the patient to re-orientate, close monitoring of vital signs and adequate hydration, and symptomatic treatment for agitation, autonomic instability, and hallucinations. In symptomatic treatment of DT, benzodiazepines are most commonly preferred due to their GABA-ergic effects. Diazepam, a benzodiazepine, has a faster onset of action than other benzodiazepines when administered intravenously (iv) and effectively controls symptoms. Although low doses of diazepam usually relieve DT symptoms, very high doses may be required in some patients. This case series discusses patients receiving high doses of diazepam to relieve DT symptoms.

CASE REPORT

Four male patients aged from 43 to 57 years who regularly consumed alcohol with a daily average of 20-100 standard drinks and developed DT afterwards and were followed up in the intensive care unit are presented. In these patients, the symptoms of DT were relieved, and somnolence was achieved with the administration of very high-dose IV diazepam (260-480 mg/day), contrary to routine treatment doses. All patients were successfully treated and discharged without any morbidity.

CONCLUSION

Severe AWS can potentially result in death otherwise managed quickly and adequately. Diazepam is a suitable agent for severe AWS or DT treatment. Clinicians should keep in mind that high-dose diazepam treatment may be required in the treatment of DT that develops after a long-term and high amount of alcohol consumption. Publications reporting the need for very high doses of diazepam in DT are limited and usually published long ago; in this context, our findings are significant. The evidence is often based on case reports and uncontrolled studies, so controlled trials are needed to determine optimal treatment doses in severe DT.

Molecular mechanisms of alcohol's effects on the human body: A review and update

Alcohol consumption has been linked to numerous negative health outcomes although it has some beneficial effects on moderate dosages, the most severe of which being alcohol-induced hepatitis. The number of people dying from this liver illness has been shown to climb steadily over time, and its prevalence has been increasing. Researchers have found that alcohol consumption primarily affects the brain, leading to a wide range of neurological and psychological diseases. High-alcohol-consumption addicts not only experienced seizures, but also ataxia, aggression, social anxiety, and variceal hemorrhage that ultimately resulted in death, ascites, and schizophrenia. Drugs treating this liver condition are limited and can cause serious side effects like depression. Serine-threonine kinases, cAMP protein kinases, protein kinase C, ERK, RACK 1, Homer 2, and more have all been observed to have their signaling pathways disrupted by alcohol, and alcohol has also been linked to epigenetic changes. In addition, alcohol consumption induces dysbiosis by changing the composition of the microbiome found in the gastrointestinal tract. Although more studies are needed, those that have been done suggest that probiotics aid in keeping the various microbiota concentrations stable. It has been argued that reducing one's alcohol intake may seem less harmful because excessive drinking is a lifestyle disorder.

Mortality and alcohol-related morbidity in patients with delirium tremens, alcohol withdrawal state or alcohol dependence in Norway: A register-based prospective cohort study

BACKGROUND AND AIMS

Little is known about long-term consequences of delirium tremens (DT). This study aimed to compare all-cause and cause-specific mortality and alcohol-related morbidity between patients with: (i) DT, (ii) alcohol withdrawal state (AWS) and (iii) alcohol dependence (AD).

DESIGN

A national longitudinal health registry study with linked data from the Norwegian Patient Registry and the Norwegian Cause of Death Registry.

SETTING

Norway.

PARTICIPANTS

All patients registered in the Norwegian Patient Registry between 2009 and 2015 with a diagnosis of AD (ICD-10 code F10.2), AWS (F10.3) or DT (F10.4) and aged 20-79 years were included (n = 36 287).

MEASUREMENTS

Patients were categorized into three mutually exclusive groups; those with DT diagnosis were categorized as DT patients regardless of whether or not they had received another alcohol use disorder diagnosis during the observation period or not. Outcome measures were: annual mortality rate, standardized mortality ratios (SMR) for all-cause and cause-specific mortality and proportion of alcohol-related morbidities which were registered in the period from 2 years before to 1 year after the index diagnosis.

FINDINGS

DT patients had higher annual mortality rate (8.0%) than AWS (5.0%) and AD (3.6%) patients, respectively. DT patients had higher mortality [SMR = 9.8, 95% confidence interval (CI) = 8.9-10.7] than AD patients (SMR = 7.0, 95% CI = 6.8-7.2) and AWS patients (SMR = 7.8, 95% CI = 7.2-8.4). SMR was particularly elevated for unnatural causes of death, and more so for DT patients (SMR = 26.9, 95% CI = 21.7-33.4) than for AD patients (SMR = 15.2, 95% CI = 14.2-16.3) or AWS patients (SMR = 20.1, 95% CI = 16.9-23.9). For all comorbidities, we observed a higher proportion among DT patients than among AWS or AD patients (P < 0.001).

CONCLUSIONS

People treated for delirium tremens appear to have higher rates of mortality and comorbidity than people with other alcohol use disorders.

The Effect of Shared Decision-Making by Mental Health Nurses on Medication Adherence in Patients with Alcohol Use Disorders: Provider-Patient Communication Pathway Model

The involvement of patients with mental health issues in their own treatment decision-making has often been overlooked. This study aimed to investigate the impact of shared decision-making between mental health nurses and patients with alcohol use disorders (AUD) on medication adherence. The provider-patient communication pathway model was utilized to examine the ways in which therapeutic communication strategies employed by mental health nurses positively influence medication adherence. The study employed a percentile bootstrap method and pairwise comparison tests in structural equation modeling. The results revealed that shared decision-making between AUD patients and mental health nurses directly enhanced medication adherence, as well as indirectly influenced adherence through the mediating factors of therapeutic alliance and alcohol abstinence self-efficacy. These findings hold both theoretical and practical implications for involving patients with AUD in therapeutic decision-making within psychiatric and mental health nursing settings, as well as for improving medication adherence among this patient population.

Risk factors for hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer

OBJECTIVE

This study aimed to analyze the risk factors for the occurrence of postoperative hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia in patients with gastric cancer.

METHODS

The clinical data of 280 gastric cancer patients who underwent laparoscopic radical gastrectomy under general anesthesia in First Affiliated Hospital of Gannan Medical University from January 2020 to June 2023 were retrospectively analyzed, and the types and incidence of postoperative delirium were recorded. The factors influencing the occurrence of postoperative hyperactive delirium were analyzed.

RESULTS

Multi-factor logistic regression analysis showed that older age, high dosage of anesthetic drug consumption, high American Society of Anesthesiologists (ASA) classification (or ASA grade 3-4), long Post-anesthesia Care Unit (PACU) stay, and long extubation time were independent risk factors for the occurrence of hyperactive delirium after laparoscopic radical gastrectomy (OR > 1, P < 0.05). The area under the curve of the nomogram was used to predict the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia was 0.903 (95% CI: 0.846-0.978).

CONCLUSION

Older age, high dosage of anesthetic drug consumption, high ASA classification (or ASA grade 3-4), long PACU stay, and long extubation time were independent risk factors affecting the occurrence of hyperactive delirium after laparoscopic radical gastrectomy under general anesthesia.

Alcohol and the central nervous system

Ethanol use is common to most cultures but with varying doses and to varying extents. While research has focused on the effects on the liver, alcohol exerts a range of actions on the function and structure of the nervous system. In the central nervous system (CNS) it can provoke or exacerbate neurological and psychiatric disease; its effects on the peripheral nervous system are not included in this review. Sustained alcohol intake can predispose to acute neurochemical changes which, with continued ingestion and incomplete treatment, can lead to chronic structural changes in the CNS: these include generalised cortical and cerebellar atrophy, amnesic syndromes such as Korsakoff's syndrome, and specific white matter disorders such as central pontine myelinolysis and Marchiafava-Bignami syndrome. Alcohol in pregnancy commonly and significantly affects fetal health, though this receives less medical and political attention than other causes of fetal harm. This review looks at the range of disorders that can follow acute or chronic alcohol use, and how these should be managed, and we provide a practical overview on how neurologists might diagnose and manage alcohol addiction.

Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar)

AIM

Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP).

METHOD

Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests.

RESULTS

SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001.

CONCLUSION

The SEWS is the superior measure of AWS symptoms.

[Antipsychotic Treatment of Alcohol Withdrawal Syndrome with Focus on Delirium Tremens: a Systematic Review]

BACKGROUND

Delirium tremens (DT) is a common complication of alcohol withdrawal. Pharmacological treatment of hospitalized patients with DT is important in addiction medicine but also in other medical disciplines where DT can occur as a complication of hospitalization. Patients suffering from DT require treatment with benzodiazepines (short-acting benzodiazepines for elderly patients to reduce accumulation), and in cases of psychotic symptoms, treatment with antipsychotics. Benzodiazepines are a first-line treatment for DT. A specific guideline for the use of antipsychotics has yet to be developed. This review discusses the current guidelines and literature on the antipsychotic treatment options in DT.

AIM

Systematic presentation of relevant antipsychotics for the treatment of DT.

METHODS

A systematic literature search was conducted using Scopus and PubMed. The last search was conducted on May 22nd 2022. Original articles and reviews on antipsychotic treatment in alcohol withdrawal and DT were included in this review. Further, international guidelines were also considered. The review was registered using the PROSPERO database (https://www.crd.york.ac.uk/prospero/); CRD42021264611.

RESULTS

Haloperidol is mainly recommended for use in the intensive care unit. There is little literature on the use of atypical antipsychotics to treat DT. Treatment with antipsychotics always should be combined with benzodiazepines, and physicians should watch out for complications like neuroleptic malignant syndrome, QTc interval prolongation, extrapyramidal symptoms and withdrawal seizures resulting from lowering the threshold for seizures.

CONCLUSION

Antipsychotic treatment should depend on the experience of the physician. Beside haloperidol, no other clear recommendations are available.

Neutrophil-lymphocyte ratio as a predictor of delirium tremens in hospitalized patients with alcohol withdrawal

Delirium Tremens (DT) is a severe form of alcohol withdrawal that can be fatal if not recognized early and treated appropriately. In our study, we aimed to determine the role of Neutrophil-Lymphocyte ratio (NLR), a marker of systemic inflammation, in predicting the development of DT. This retrospective study was conducted in an alcohol and drug treatment center between March 2017 and March 2020. A total of 212 patients with a diagnosis of alcohol use disorder who were admitted to a special care unit after alcohol withdrawal were included. Blood tests were collected within 24 hours of the patients' admission. Comparisons were made according to whether the patients developed DT during the hospitalization. DT was diagnosed in 24.1% of the patients. It was determined that higher NLR level (odds ratio [OR]: 4.38, 95%CI: 2.58-7.43) and history of DT (OR: 1.33, 95%CI: 1.23-11.73) are independent risk factors for the development of DT in the logistic regression analysis. The optimal cut-off value of NLR in predicting DT was 2.67 (sensitivity: 82.4%, specificity: 88.8%). The ROC curve of NLR showed a larger area under the curve (AUC) than the curves of other systemic inflammation markers. NLR is a simple, practical and inexpensive marker that can predict the development of DT in patients with alcohol withdrawal syndrome.

Prevention of alcohol withdrawal syndrome in the surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Alcohol withdrawal syndrome is a common and challenging clinical entity present in trauma and surgical intensive care unit (ICU) patients. The screening tools, assessment strategies, and pharmacological methods for preventing alcohol withdrawal have significantly changed during the past 20 years. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews the best practices for screening, monitoring, and prophylactic treatment of alcohol withdrawal in the surgical ICU.

Management of Alcohol Withdrawal Syndrome in Patients with Alcoholic Liver Disease

Alcohol withdrawal syndrome (AWS) is a common condition that is seen in treatment-seeking patients with Alcohol use disorder (AUD) and alcoholic liver disease (ALD). AWS, which typically starts within 4-6 h of the last alcohol use, can range from mild symptoms such as insomnia, tremors, and autonomic hyperactivity to more severe symptoms such as seizures and delirium tremens. Clinical Institute Withdrawal Assessment Scale-Alcohol Revised (CIWA-Ar) is the most commonly used scale to assess AWS in clinical practice. The presence of moderate withdrawal as indicated by a score of more than 8 is an indication for pharmacotherapy. Lorazepam and oxazepam are preferred agents for the management of AWS in the setting of ALD. In severe ALD, benzodiazepines should be used cautiously with monitoring due to the risk of excessive sedation or precipitating hepatic encephalopathy.

Plasma tau, NfL, GFAP and UCHL1 as candidate biomarkers of alcohol withdrawal-associated brain damage: A pilot study

In this translational study, we investigated the plasma tau protein, neurofilament light chain (NfL), glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCHL1), which are established biomarkers of neurological injury, as predictive biomarkers of alcohol withdrawal-associated brain toxicity. In the clinical study, patients with severe alcohol use disorder (AUD) on D1 of hospitalization for alcohol cessation (AC) (N = 36) were compared to severe AUD patients with at least 3 months of abstinence (N = 16). Overall, patients were 40 men (76.9%), aged 49.8 years [SD ±9.9]. Tau, NfL, GFAP and UCHL1 levels were measured using SIMOA and analysed with a quasipoisson regression model adjusted for age and sex. The NfL level was higher in the AC group (p = 0.013). In the AC group, the tau (p = 0.021) and UCHL1 (p = 0.021) levels were positively associated with the dose of diazepam per weight, and the tau (p = 0.045), NfL (p = 4.9 × 10^-3 ) and UCHL1 (p = 0.036) levels were higher in the presence of signs of Wernicke's encephalopathy (n = 9). In the preclinical study, NfL and GFAP levels were assessed in the alcohol deprivation effect (ADE) procedure (N = 17) and control Wistar rats (N = 15). Furthermore, ADE rats were prospectively assessed: after 24 h (T1) and 3 weeks of AC (T2) (paired-samples Wilcoxon and Mann-Whitney tests). The NfL level was higher in the ADE model than in the control rats at both T1 and T2 (p = 0.033 and p = 1.3 × 10^-3 ) and higher at T2 than at T1 (p = 0.040). Plasma tau, NfL and UCHL1 are potential biomarkers of brain suffering during alcohol withdrawal.

History of Delirium Tremens in AUD Patients in Treatment: Relationship to AUD Severity and Other Factors

Introduction

Delirium tremens (DT) occurs after stopping prolonged, high alcohol intake and may be life-threatening if untreated. We need to know about clinical correlates of DT in order to provide the best clinical care.

Methods

At admission to inpatient treatment a cohort of 114 alcohol use disorder (AUD) patients were interviewed and examined concerning psychiatric diagnosis and symptoms, trauma experiences and alcohol related measures and if they had experienced DT.

Results

Twenty-four percent of the patients reported a life-time experience of DT. These patients were predominantly males and had lower educational level. More of the patients in the DT than the non-DT group reported at least one suicide attempt, were diagnosed with PTSD, and dropped out of treatment. Also, having parents with alcohol problems was more common among these patients, and they reported a longer duration of problematic drinking and a higher number of drinks needed to feel an effect of drinking. In the multivariable adjusted analysis only a diagnosis of PTSD (OR=5.71; 95% confidence interval (CI): 1.34–24.31) and duration of problematic drinking with a 6% increase in risk for every year (OR=1.06; 95% CI: 1.01–1.11) remained significant risk factors for having DT experience.

Discussion and conclusion

Having experienced DT was more prevalent in the current investigation than in earlier studies. Patients that had experienced DT seemed to have more serious AUD, especially signified by a longer duration of drinking. These patients seemed to have many clinical disadvantages including more drop-out and higher suicide rate. PTSD could be a risk factor for DT but may also follow the DT experience.

Chlordiazepoxide-induced delirium in a patient undergoing alcohol withdrawal: a case report

Background

Ethanol dependence is associated with a discontinuation withdrawal delirium. Chlordiazepoxide is frequently successfully used in its treatment.

Case presentation

A 27-year-old, Caucasian female with ethanol dependence who had objective symptoms of withdrawal experienced worsening of her delirium after administration of chlordiazepoxide, but improved with lorazepam and cleared with discontinuation of benzodiazepine administration.

Conclusions

Worsening of delirium appears to be related to the specific use of chlordiazepoxide, but the mechanism of this effect is not clear. While this case does not alter the standard care of ethanol dependence, it does alert clinicians that our treatment approach may not be fully benign.

Complications of Ethanolic Withdrawal in Hospitalized Patients

Chronic alcohol consumption, also called alcoholism, is a chronic disease characterized by compulsive alcohol consumption, loss of control over alcohol consumption and a negative emotional state in the absence/lack of consumption. Statistics show that the incidence of alcohol consumption in the adult population has been increasing during the isolation due to the pandemic. It is fre-quently associated with the consumption of other substances, in which case mortality is higher than in the case of single alcohol consumption. The patterns of alcohol consumption are varied, being related to a series of demographic, social, psychological and behavioral variables. The most worrying aspect of alcohol consumption is represented by the increase in the frequency of this type of addiction among teenagers and young people. It should also be mentioned that there is an increase in the incidence in females and there are new variables related to the context of consumption: increased boredom, alcohol consumption for the purpose of relaxation and alcohol consumption as an activity in the absence of an entourage. During the pandemic, there was also the myth that alcohol consumption would be the basis for reducing the risk of contamination with the SARS CoV 2 virus, an aspect disproved by specialist studies. The increased consumption of alcohol during the pandemic could be correlated with anxiety and depression determined by the fear of illness and depression due to the loss of the job, the lack of social relations or online education, being unanimously accepted that alcohol has an anxiolytic role. Regarding ethanolic withdrawal (EW) symptoms, studies show that approximately 50% of patients with chronic alcohol consumption will develop withdrawal symptoms when they reduce the quantity of alcohol or stop drinking alcohol.

REM sleep behavior disorder: Mimics and variants

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia with dream-enactment behaviors occurring during REM sleep and associated with the lack of the physiological REM sleep muscle atonia. It can be isolated and secondary to other neurological or medical conditions. Isolated RBD heralds in most cases a neurodegenerative condition due to an underlying synucleinopathy and consequently its recognition is crucial for prognostic implications. REM sleep without atonia on polysomnography is a mandatory diagnostic criterion. Different conditions may mimic RBD, the most frequent being obstructive sleep apnea during sleep, non-REM parasomnia, and sleep-related hypermotor epilepsy. These diseases might also be comorbid with RBD, challenging the evaluation of disease severity, the treatment choices and the response to treatment evaluation. Video-PSG is the gold standard for a correct diagnosis and will distinguish between different or comorbid sleep disorders. Careful history taking together with actigraphy may give important clues for the differential diagnosis. The extreme boundaries of RBD might also be seen in more severe and complex conditions like status dissociatus or in the sleep disorders' scenario of anti IgLON5 disease, but in the latter both clinical and neurophysiological features will differ. A step-by-step approach is suggested to guide the differential diagnosis.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

The man behind the bed: a case of peduncular hallucinosis treated with quetiapine and melatonin

An 81-year-old female presented with a right pontine infarct and later developed recurrent vivid hallucinations. After a workup for delirium and hallucinosis was unrevealing, a diagnosis of peduncular hallucinosis (PH) was proposed. Treatment with quetiapine and, later, adjunctive nightly melatonin resulted in return to cognitive baseline. An array of etiologies can be responsible for visual hallucinations, including PH. Herein, we review several disorders of hallucinosis and their diagnostic workup. Additionally, we explore the pathophysiology of PH and its association with the pontine-geniculate-occipital (PGO) pathway and propose why correction of the sleep-wake cycle may benefit patients with PH.

Catatonia Presentation as a Rare Alcohol Withdrawal Symptom in a Patient With No Past Psychiatry History: A Case Report

A complicated alcohol withdrawal syndrome (AWS) includes epileptic seizures and/or delirium tremens (DT). However, there is still a dearth of literature for catatonia as a consequence of AWS especially in terms of clinical reports. Secondly, the few noted reported cases in the literature were mainly of non-American populations. Hence, we present the case of a middle-aged woman with no past psychiatric history admitted for psychosis and altered sensorium with delayed catatonic features in the context of a history of alcohol use disorder. Ms. M., a 44-year-old African American female with no past psychiatric history but a past medical history of gastric bypass surgery, presented to the psychiatric emergency department via emergency medical service due to roaming the street because of acute onset of altered mental status and psychotic features. She had a Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) score of 33 following last alcohol use a few hours prior to presentation. While on the inpatient unit, the patient had an isolated episode of catatonic stupor despite being administered lorazepam 2mg every four hours as needed. Supportive medical staff should also be aware of catatonia as a rare manifestation of alcohol withdrawal. A persistent, thorough medical workup and evidence-based "investigative" history gathering can help elucidate the source of the presenting symptom in this patient population.

Management of Alcohol Withdrawal in the Emergency Department: Current Perspectives

Alcohol withdrawal syndrome (AWS) is a common, heterogenous, and life-threatening complication of alcohol use disorder (AUD). AUD is a leading cause of worldwide mortality, and many patients with AUD will develop AWS during their ED course. This review summarizes the epidemiology, pathology, and management of AWS and AUD in the emergency setting. The time course of AWS and its impact on ED treatment is emphasized. Once AWS is diagnosed, symptom-triggered benzodiazepine administration remains the most commonly provided treatment but may not be appropriate for patients with significant medical or psychiatric comorbidity or pending discharge. In these cases, ED clinicians may consider short courses of barbiturates or alternative regimens based on novel anticonvulsants. Specific treatment protocols are enumerated for clinical practice. Finally, emergency providers must not only manage acute patients' AWS but also lay the foundation for successful treatment of AUD. An approach to the disposition of the patient with AUD is presented. The authors examine shortcomings in the extant literature and suggest opportunities for further study.

Acute inferior ST-elevation myocardial infarction due to delirium tremens: a case report

Background

Delirium tremens is a severe form of alcohol withdrawal syndrome. Literature documenting acute coronary events in the setting of alcohol withdrawal remains scarce. An accepted hypothesis for the underlying process is focused on the hyperadrenergic state that leads to coronary vasospasm and increased myocardial oxygen demand.

Case presentation

A 47-year-old Caucasian man with a past medical history of tobacco and alcohol abuse, hypertension, and anxiety presented to the emergency department for crampy epigastric abdominal pain with intractable nausea and vomiting for the past 2 days. His reported last alcoholic intake was about 10 days prior; however, outpatient records indicated otherwise. He was admitted for electrolyte replacement and fluid resuscitation secondary to gastrointestinal losses from presumed early alcohol withdrawal syndrome. The following night, he developed acute substernal chest pain with elevated cardiac enzymes. Electrocardiography showed an acute inferoposterior infarct with reciprocal changes in leads V1–V4. The patient was taken for emergent catheterization, and a drug-eluting stent was placed in the middle of the left anterior descending artery. Postcatheterization electrocardiography showed sustained inferolateral ST elevations consistent with acute injury pattern. The patient had not required any benzodiazepines until this point. On the morning of catheterization, the patient’s Clinical Institute Withdrawal Assessment for Alcohol–Revised score was 19 with a high of 25, and he was actively hallucinating. He was treated for delirium tremens and an acute coronary event along with an incidental pneumonia. He did not require any benzodiazepines during the last 4 days of admission, and he made a full recovery.

Conclusions

The prevalence of alcohol dependence in hospitalized patients is substantial. Although our patient was being treated with the standard protocols for alcohol withdrawal, he rapidly developed delirium tremens, which led to an acute inferior ST-elevation myocardial infarction in the setting of nonoccluded coronary vessels. This case report adds to the sparse literature documenting acute coronary events in the setting of alcohol withdrawal and suggests that our patient’s ST-elevation myocardial infarction is not fully explained by the current coronary vasospasm hypothesis, but rather was in part the result of direct catecholamine-associated myocardial injury. Further research should be conducted on prophylactic agents such as β-blockers and calcium channel blockers.

Delusional Parasitosis in a Patient with Alcohol-induced Psychotic Disorder

Alcohol-induced psychotic disorder is a rare complication of chronic alcohol abuse following abrupt alcohol cessation that is characterized by visual, auditory, or tactile hallucinations paired with intact orientation and stable vital signs, distinguishing the condition from delirium tremens and psychotic disorders. The condition, first termed alcoholic hallucinosis, has been described in medical literature for over a century, however, its nosologic classification and psychopathologic characteristics are less well-documented. One such case of alcohol-induced psychotic disorder with multimodal hallucinations of four months duration is described here.