A 46-year-old man is admitted to the hospital due to right hand cellulitis. He has a history of intravenous drug and problematic alcohol use, hepatitis C infection, and septic arthritis of the knee. Treatment with vancomycin is initiated. The day after admission, the cellulitis has improved; however, the patient now reports that he sees bats flying around his room. He says that he has never experienced visual hallucination before. Temperature is 37.5 C (99.5 F), blood pressure is 131/89 mm Hg, pulse is 93/min, and respirations are 18/min. Examination shows decreased right hand swelling and redness, mild tremors bilaterally, and diaphoresis. The patient is alert and oriented but appears frightened. Which of the following is the most appropriate next step in management of this patient?

Question

A 46-year-old man is admitted to the hospital due to right hand cellulitis.  He has a history of intravenous drug and problematic alcohol use, hepatitis C infection, and septic arthritis of the knee.  Treatment with vancomycin is initiated.  The day after admission, the cellulitis has improved; however, the patient now reports that he sees bats flying around his room.  He says that he has never experienced visual hallucination before.  Temperature is 37.5 C (99.5 F), blood pressure is 131/89 mm Hg, pulse is 93/min, and respirations are 18/min.  Examination shows decreased right hand swelling and redness, mild tremors bilaterally, and diaphoresis.  The patient is alert and oriented but appears frightened.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

The abrupt onset of hallucinations in this patient with a known history of problematic alcohol use who exhibits classic signs of alcohol withdrawal (ie, tremors, diaphoresis, autonomic hyperactivity) after a period of forced abstinence (ie admission to the hospital) is consistent with alcoholic hallucinosis. Alcoholic hallucinosis usually presents within 24 hours of the last drink and resolves within 48 hours. The most common type of hallucination seen in alcoholic hallucinosis is visual, but tactile and auditory hallucinations are also possible. If hallucinations occur >48 hours after the last drink and are accompanied by delirium and severe autonomic hyperactivity, delirium tremens should be suspected. Delirium tremens is associated with a mortality rate as high as 5%. Patients with moderate to severe alcohol withdrawal, such as this patient, should be treated with benzodiazepines to control agitation and prevent progression of withdrawal (eg, seizures, delirium tremens). Lorazepam is the preferred choice in patients with liver disease because it has no active metabolites. (Choice A) Side effects of vancomycin include ototoxicity, "red man syndrome" (a pseudoallergic reaction characterized by flushing and pruritus), and nephrotoxicity. Vancomycin is improving this patient's infection and is not causing his symptoms. (Choice B) This patient has no localizing signs or symptoms that suggest a neurologic lesion and shows classic signs of alcohol withdrawal. (Choices C and F) Antipsychotics such as haloperidol and olanzapine are not indicated for the treatment of alcoholic hallucinosis, which resolves with the treatment of the underlying alcohol withdrawal. Antipsychotics may lower the seizure threshold and should be avoided in the seizure-prone state of alcohol withdrawal. (Choice E) Methadone is a long-acting opioid commonly used both for opioid withdrawal and chronic management of heroin addiction. Although this patient has a history of intravenous drug abuse that may include opiates, his current symptoms are more characteristic of alcohol withdrawal. Opioid withdrawal can be identified by dilated pupils, piloerection, dysphoria, myalgias, and abdominal pain. Educational objective: Alcoholic hallucinosis usually presents in the first 24 hours after the last drink and is typically associated with other symptoms of alcohol withdrawal (eg, tremor, anxiety, diaphoresis, autonomic hyperactivity). Treatment consists of benzodiazepines to control agitation and prevent progression of withdrawal. References: Management of acute alcohol withdrawal syndrome in critically ill patients. (http://www.ncbi.nlm.nih.gov/pubmed/27196747) Alcohol withdrawal syndrome: benzodiazepines and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/26500991)

A 46-Year-Old Man Is Admitted to the Hospital Due to Right