Differential Diagnosis for Altered Mental Status after Alcohol Withdrawal

• Single most likely diagnosis
  • Delirium Tremens (DTs): This is the most likely diagnosis given the context of alcohol withdrawal. DTs is a severe form of alcohol withdrawal that occurs usually 48-72 hours after the last drink, characterized by altered mental status, hallucinations, and significant autonomic instability.
• Other Likely diagnoses
  • Alcohol Withdrawal Syndrome: While DTs is a part of the alcohol withdrawal syndrome, not all patients will progress to DTs. Altered mental status can be a part of the broader syndrome, which includes a range of symptoms from mild anxiety and tremors to more severe manifestations.
  • Wernicke's Encephalopathy: This condition, caused by thiamine deficiency, is common in chronic alcohol users and can present with altered mental status, ataxia, and ophthalmoplegia. It's a consideration in any patient with a history of alcohol abuse presenting with neurological symptoms.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Intracranial Hemorrhage: Although less common, an intracranial hemorrhage could present with altered mental status and has a high mortality rate if not promptly diagnosed and treated. The physical stress of alcohol withdrawal could potentially contribute to the risk of hemorrhage.
  • Infections (e.g., Meningitis, Encephalitis): Infections of the central nervous system can present with altered mental status and are medical emergencies. Patients with a history of alcohol abuse may be more susceptible to certain infections due to compromised immune function.
  • Seizures (post-ictal state): Seizures can occur during alcohol withdrawal, and a post-ictal state could present as altered mental status. Missing this diagnosis could lead to further seizures or status epilepticus.
• Rare diagnoses
  • Marchiafava-Bignami Disease: A rare condition associated with chronic alcohol abuse, characterized by demyelination of the corpus callosum, which can lead to altered mental status, seizures, and other neurological symptoms.
  • Central Pontine Myelinolysis: Another rare condition that can occur in the setting of rapid correction of hyponatremia, often seen in alcoholics, leading to demyelination of the pons and presenting with altered mental status among other symptoms.