Maaike Plug
When reading the title, you will possibly think of the Belgian beer ‘Delirium Tremens’, which has a pink elephant as a logo. This beer is very popular among many students on the Friday afternoon drink at the Aesculaaf. But it is also the name of a type of delirium caused by withdrawal from alcohol. According to DSM-5, the criteria for delirium tremens are a reduction in heavy use of alcohol, two or more of the eight symptoms after reducing alcohol consumption, a decreased attention and awareness, abnormalities in brain functions and no signs of coma or other neurocognitive disorders [1].
When refraining from alcohol, the following symptoms may occur: autonomic hyperactivity, hand tremor, nausea or vomiting, anxiety, insomnia, seizures and hallucinations [1]. The seizures may result in death, whereby alcohol can be dangerous to withdraw [2, 3]. Therefore, treatment is necessary when patients go through alcohol withdrawal
The most used treatment for the symptoms of alcohol withdrawal are benzodiazepines [2]. Benzodiazepines have the same effect as alcohol in the brain, namely increasing the release of g-aminobutyric acid (GABA) [2]. GABA is a neurotransmitter, and has an effect on the central nervous system. It causes somnolence, which is a decreased coordination and concentration and forgetfulness [4]. When patients withdraw from alcohol, there will be a decrease of GABA in the brain. This will result in fear, irritability, seizures and less sleep [4]. When benzodiazepines are given, the presence and degree of these symptoms will be decreased. Patients will also receive supplemental thiamine, folic acid and multivitamins to supplement the vitamin shortage caused by excessive alcohol use [5]. With the medication and supplements, patients will withdraw from alcohol with less problems.
However, when patients do not recover with the help of medication, you need to make sure there is no other cause for the delirium. Tanabe et al. described that an infection with Campylobacter fetus, which is called meningoencephalitis, can cause the same symptoms as with withdrawal of alcohol [6]. Infections of the Campylobacter fetus occur mostly among patients who are immunocompromised, due to corticosteroid therapy, malignancy, diabetes or hepatic failure [6]. The researchers found a relationship between chronic alcoholism and Campylobacter fetus meningoencephalitis [6]. Unfortunately, there is no treatment protocol for the therapy of this infection, but the mortality is high when it remains untreated [6]. Therefore, a clear and fast distinction between these two causes of delirium tremens is necessary.
Conclusively, delirium tremens is a condition mostly caused by withdrawal of alcohol. However, Campylobacter fetus can also provoke the symptoms that match with delirium tremens. It is important to distinguish the possible causes of delirium and act fast to prevent further damage. Nevertheless, delirium tremens is also a delicious beer to enjoy with friends, according to many people. Drink responsibly though, before the pink elephant you see is not from the bottle.
[1] Association, A. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5®). (American Psychiatric Publishing, 2013).
[2] Schuckit, M. Recognition and Management of Withdrawal Delirium (Delirium Tremens). New England Journal of Medicine 371, 2109-2113 (2014).
[3] Fisher, G. & Roget, N. Encyclopedia of substance abuse prevention, treatment, & recovery. (SAGE, 2009).
[4] Hall, W. & Zador, D. The alcohol withdrawal syndrome. The Lancet 349, 1897-1900 (1997).
[5] Ferguson, J., Suelzer, C., Eckert, G., Zhou, X. & Diffus, R. Risk factors for delirium tremens development. Journal of General Internal Medicine 11, 410-414 (1996).
[6] Tanabe, S. et al. Meningoencephalitis Caused by a Campylobacter fetus in a Patient with Chronic Alcoholism. Internal Medicine (2019).