A 55-year-aged chronic alcoholic male, presented with irrelevant talks, tremor and sweating. He had his last drink 3 days back. What will the probable diagnosis?
Ans. a. Delirium tremensRef: Kaplan Step 2 CK Lecture Notes 2018 of Psychiatry; Page No- 40 & Kaplan Step 2 CK Lecture Notes 2018 of Internal medicine; Page No-369DELIRIUM TREMENS (DT)Manifests 48-72 hours after the last drink but can last up to 10 days.Mental confusionAutonomic hyperactivityVisual hallucinationsSevere agitationDiaphoresisALCOHOLIC HALLUCINOSISMay be confused with DTStarts 12-24 hours after last drink but can last days to weeksParanoid psychosis without tremors and confusionNormal vital signs (no hypertension or tachycardia)No agitationNormal appearance except for auditory (most common), visual, or tactile hallucinations.WERNICKE ENCEPHALOPATHYConfusion, ataxia, and ophthalmoplegia (nystagmus).KORSAKOFF PSYCHOSISAmnesia and confabulations.TREATMENTAlcohol withdrawal has a very high mortality rate (5%).Benzodiazepines can be life-saving (important to taper dose slowly). Diazepam and chlordiazepoxide are common, due to their long half-life. There is no role for anticonvulsants.Antipsychotics such as haloperidol should be avoided because they can lower the seizure threshold and cause prolonged QT interval.Hydrate with isotonic fluids and electrolyte replacement. Symptom-triggered therapy is recommended. A work-up for alternative diagnosis is also very important.Use only lorazepam or oxazepam for cirrhosisCT head to look for intracranial bleedLumbar puncture to rule out meningitis if there is a feverChest x-ray: Look for aspiration pneumoniaHigh doses of thiamine IV for Wernicke and Korsakoff. Treatment for alcoholic hallucinosis is benzodiazepines and haloperidol (there is no risk of seizures, so it can be used here).
Delirium tremens
Korsakoff psychosis
Postacute withdrawal syndrome
Discontinuation syndrome
Substance Abuse