A 40 year old chronic alcoholic is brought to the hospital emergency room with acute onsent of seeing snakes all around him in the room, not recognizing family members, violent behavior and tremulousness for few hours. He has missed the alcohol drink since 2 days. Examination reveals increased blood pressure, tremors, increased psychomotor activity, fearful affect, hallucinatory behaviour, disorientation, impaired judgement and insight. What is he is most likely to be suffering from?

**Core Concept:** Delirium tremens (DTs) is a severe form of alcohol withdrawal syndrome that occurs in individuals who have abruptly stopped consuming alcohol after prolonged abuse.

**Why the Correct Answer is Right:** The patient described in the question presents with acute onset of neurological symptoms and signs, including hallucinations (perceiving snakes), disorientation, impaired judgment, and altered behavior. This is most consistent with Delirium tremens (DTs), a severe form of alcohol withdrawal syndrome. The patient's history of chronic alcoholism, absence of alcohol for two days, and the presence of these symptoms support the diagnosis of DTs.

**Why Each Wrong Option is Incorrect:**

A. Acute alcohol withdrawal (AW) is a milder form of alcohol withdrawal syndrome typically presenting with tremors, agitation, and insomnia. While the patient may exhibit some symptoms of AW, the severe hallucinations and disorientation are not typical of AW.

B. Acute schizophrenia-like psychosis is a differential diagnosis for psychotic symptoms. However, the patient's history of chronic alcoholism, abrupt cessation of alcohol, and the presence of tremors and agitation are more consistent with DTs.

C. Acute mania is a differential diagnosis for psychotic symptoms. Similar to option B, the patient's history of chronic alcoholism, abrupt cessation of alcohol, and the presence of tremors and agitation are more consistent with DTs.

D. Acute stroke is a potential differential diagnosis due to neurological symptoms and signs. However, the patient's history of chronic alcoholism, abrupt cessation of alcohol, and the presence of tremors, agitation, hallucinations, disorientation, and impaired judgment are more consistent with DTs.

**Clinical Pearl:** Recognizing and managing alcohol withdrawal syndromes like DTs is crucial in clinical practice, especially in emergency settings where patients may present with severe neurological and psychiatric symptoms. Early recognition and management are essential to prevent complications, such as seizures and status epilepticus, which can be life-threatening.

**Correct Answer Explanation:**

Correct Answer: DT (Delirium Tremens)

Delirium tremens is a severe form of alcohol withdrawal syndrome that occurs in patients with prolonged alcohol abuse who abruptly stop alcohol intake. DTs are characterized by neurological symptoms, such as tremors, agitation, and hallucinations, along with psychiatric symptoms like disorientation, impaired judgment, and altered mental status. The patient's history of chronic alcoholism, abrupt cessation of alcohol, and the presence of tremors, agitation, hallucinations, disorientation, impaired judgment, and altered mental status are more consistent with DTs than the other options. Early recognition and management are crucial to prevent severe complications such as seizures and status epilepticus.

✓ Correct Answer: B. Delirium tremens