Psychiatry · Year 2 · from Psychiatry
Case 1: Alcohol Use Disorder with Severe Withdrawal
Patient Presentation
Demographics: 52-year-old male
Chief Complaint: "I'm shaking and I think I saw bugs crawling on the wall."
History of Present Illness: A 52-year-old man presents to the emergency department with tremors, anxiety, and nausea. He reports drinking approximately one pint of vodka daily for the past 10 years. He has tried to quit multiple times but "always goes back." His last drink was 36 hours ago when he ran out of money. Since then, he has experienced progressively worsening tremors, profuse sweating, nausea with dry heaves, severe anxiety, and insomnia. Earlier today, he saw "bugs crawling on the walls" that he now realizes were not real. He has had two alcohol withdrawal seizures in the past, both occurring approximately 48 hours after his last drink. He has no other medical history and takes no medications. He has lost two jobs due to alcohol use and his wife left him last year. He wants help quitting this time "for real."
Physical Examination:
- Vital signs: BP 168/104, HR 118, T 38.1C, RR 22
- General: Diaphoretic, tremulous, anxious-appearing male
- Neuro: Coarse tremor of outstretched hands, no asterixis
- Skin: Spider angiomata on chest
- Abdomen: Mild hepatomegaly, no ascites
Mental Status Examination:
- Appearance: Disheveled, diaphoretic
- Behavior: Restless, tremulous
- Mood: "Anxious, scared"
- Affect: Anxious
- Thought content: No SI/HI, worried about withdrawal
- Perceptions: Reported visual hallucinations that have resolved; tactile sensation of "crawling" on skin
- Cognition: Alert, oriented x3, mildly impaired attention
Workup:
- CIWA-Ar score: 24 (severe withdrawal; >15 indicates significant withdrawal)
- Blood alcohol level: Undetectable
- CBC: Mild thrombocytopenia (112k), MCV elevated (104)
- CMP: AST 124, ALT 68, AST:ALT ratio 2:1 (suggestive of alcoholic liver disease), albumin 3.2
- Magnesium: 1.4 mEq/L (low)
- Phosphorus: 2.3 mg/dL (low)
- GGT: 285 (elevated)
- INR: 1.2
Diagnosis: Alcohol Use Disorder, severe; Alcohol Withdrawal Syndrome, severe with history of withdrawal seizures
Treatment:
- Admitted to ICU for monitored withdrawal management
- CIWA-Ar protocol initiated with symptom-triggered benzodiazepine dosing
- Lorazepam 2-4 mg IV PRN based on CIWA score (preferable in liver disease due to glucuronidation metabolism)
- Thiamine 500 mg IV daily x 3 days BEFORE any glucose administration (to prevent Wernicke encephalopathy)
- Folate 1 mg daily, multivitamin
- Magnesium and phosphorus repletion
- IV fluids for volume repletion
- Seizure precautions given history
- On day 2: CIWA scores improved, no seizures occurred
- On day 4: Withdrawal completed, CIWA consistently <8
- Started naltrexone 50 mg daily for craving reduction (after medical clearance)
- Referral to addiction medicine and intensive outpatient program
- Discussed maintenance options: naltrexone, acamprosate, disulfiram
- Social work involved for housing and support services
Clinical Pearl: Alcohol withdrawal follows a predictable timeline: tremor and anxiety at 6-12 hours, hallucinations at 12-24 hours, seizures at 24-48 hours, and delirium tremens at 48-96 hours. Prior withdrawal seizures significantly increase risk of future seizures. Thiamine MUST be given before glucose in malnourished alcoholic patients to prevent precipitating Wernicke encephalopathy. The CIWA-Ar protocol allows symptom-triggered dosing, reducing total benzodiazepine dose compared to fixed schedules. The AST:ALT ratio >2:1 is characteristic of alcoholic liver disease.