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A 52-year-old man is admitted to the medical floor after presenting with tremors and anxiety following an unplanned cessation of alcohol use 3 days ago due to hospitalization for a fall. He reports drinking approximately a fifth of vodka daily for the past 15 years with his last drink 72 hours ago. On hospital day 3, nursing staff report he has become acutely confused, diaphoretic, and agitated. On examination, his temperature is 101.8 degrees Fahrenheit, heart rate is 132 bpm, blood pressure is 178/104 mmHg, and he is profusely diaphoretic. He is disoriented to time, place, and situation, with fluctuating level of consciousness. He reports seeing small animals crawling on the walls and bed and is picking at his hospital gown attempting to remove insects that are not present. He is tremulous with coarse bilateral hand tremors. His CIWA-Ar score is 28. Laboratory studies reveal hypokalemia, hypomagnesemia, and elevated liver enzymes. His ammonia level is within normal limits. Which of the following best describes the clinical syndrome this patient is experiencing?
Explanation
Delirium tremens is the most severe manifestation of alcohol withdrawal, typically presenting 48-96 hours after last drink with the triad of delirium (fluctuating consciousness, disorientation), vivid visual hallucinations, and severe autonomic instability. A CIWA-Ar score above 20 indicates severe withdrawal. Risk factors include prolonged heavy use, abrupt cessation, and electrolyte abnormalities. Recognition is critical due to the significant mortality risk.
Key Takeaway
Delirium tremens is identified by the combination of global confusion with fluctuating consciousness, vivid visual hallucinations, and severe autonomic instability occurring 48-96 hours after alcohol cessation in patients with chronic heavy use, and it carries significant mortality risk requiring urgent recognition.