A 42-year-old man is admitted to the hospital after sustaining fractures of his right femur and tibia in a motor vehicle collision. The patient becomes agitated, hypervigilant, and paranoid 12 hours after admission. He repeatedly tells the nurses that he can hear people in the corridor making insulting remarks about him. When hospital staff check the area near the patient's room, no one is found. Medical history is unremarkable, but psychiatric history is significant for cocaine, marijuana, and alcohol misuse. He has smoked 2 packs of cigarettes a day for the past 10 years. On examination, the patient is alert and oriented. Temperature is 37.2 C (99 F), blood pressure is 135/87 mm Hg, pulse is 85/min, and respirations are 18/min. He is slightly tremulous and diaphoretic. Within 2 days, the patient's hallucinations resolve, and his behavior returns to baseline. Soon after, he is discharged home. Which of the following is the most likely diagnosis in this patient?

Question

A 42-year-old man is admitted to the hospital after sustaining fractures of his right femur and tibia in a motor vehicle collision.  The patient becomes agitated, hypervigilant, and paranoid 12 hours after admission.  He repeatedly tells the nurses that he can hear people in the corridor making insulting remarks about him.  When hospital staff check the area near the patient's room, no one is found.  Medical history is unremarkable, but psychiatric history is significant for cocaine, marijuana, and alcohol misuse.  He has smoked 2 packs of cigarettes a day for the past 10 years.  On examination, the patient is alert and oriented.  Temperature is 37.2 C (99 F), blood pressure is 135/87 mm Hg, pulse is 85/min, and respirations are 18/min.  He is slightly tremulous and diaphoretic.  Within 2 days, the patient's hallucinations resolve, and his behavior returns to baseline.  Soon after, he is discharged home.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d496_eb22_bc81_7d6d8bf88d17_MD0003_00 This patient's history of alcohol misuse, lack of premorbid psychosis, and acute onset of auditory hallucinations shortly after hospitalization (ie, with abrupt cessation of alcohol) are most consistent with alcoholic hallucinosis. Alcoholic hallucinosis is an alcohol withdrawal syndrome characterized by hallucinations and relatively stable vital signs in an otherwise alert and oriented patient. Alcoholic hallucinosis typically presents after 12 hours of abstinence and resolves within 48 hours after the last drink. The condition is usually self-limited but can be managed with benzodiazepines. Alcoholic hallucinosis is distinct from delirium tremens even though both conditions frequently present with hallucinations. Delirium tremens, which does not present prior to 48 hours after the last drink, is characterized by disorientation and marked sympathetic hyperactivity (eg, hyperthermia, hypertension, tachycardia) (Choice E). This patient is alert and oriented, his vital signs are normal, and his hallucinations fully resolved before 48 hours (ie, hospital day 2). (Choice A) Acute stress disorder is associated with recurrent intrusive thoughts, nightmares, and flashbacks about a traumatic event and lasts ≥3 days and ≤1 month. This patient's hallucinations of people talking in the corridor do not appear to have any direct link to his car accident, and he does not exhibit other features of acute stress disorder. (Choice C) Brief psychotic disorder is characterized by sudden-onset psychotic symptoms lasting ≥1 day and ≤1 month. It is a rare disorder that can be diagnosed only after psychosis due to substance intoxication/withdrawal or a medical condition is ruled out. This patient's onset of hallucinations 12 hours following hospitalization, along with a history of alcohol abuse, is more suggestive of alcohol withdrawal-induced psychosis (ie, alcoholic hallucinosis). (Choice D) Cocaine withdrawal causes depression, anxiety, fatigue, and intense cravings. It is not commonly associated with psychosis. (Choice F) Phencyclidine intoxication can present with psychosis in addition to combative behavior, delirium, dissociative symptoms, ataxia, and nystagmus. If this patient's symptoms were due to phencyclidine intoxication, he would have been hallucinating immediately on presentation rather than a day later. Educational objective: Alcoholic hallucinosis is an alcohol withdrawal syndrome that typically presents after 12 hours of abstinence and resolves within 48 hours after the last drink. Unlike delirium tremens, it tends to present in patients who are fully oriented and with relatively stable vital signs. References: Alcohol withdrawal syndrome: benzodiazepines and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/26500991) Alcoholic hallucinosis. (http://www.ncbi.nlm.nih.gov/pubmed/24250051)

A 42-Year-Old Man Is Admitted to the Hospital After Sustaining