Acta Neuropsychiatrica 2008: 20: 152–156 All rights reserved DOI: 10.1111/j.1601-5215.2008.00285.x # 2008 The Authors Journal compilation # 2008 Blackwell Munksgaard ACTA NEUROPSYCHIATRICA Case report Delayed-onset delirium tremens – a diagnostic and management challenge Saddichha S, Manjunatha N, Sinha BNP, Khess CRJ. Delayed-onset delirium tremens – a diagnostic and management challenge. Background: Delirium tremens (DT) is one of the most serious complications of alcohol withdrawal, affecting 5–10% of in-patients with a mortality rate up to 15%. DT, characterised by delirium and tremors, appears within 48–72 h of abstinence and persists for about 5–10 days. Case presentation: We report a case of DT in a young man with delayed onset on the 15th day after the cessation of alcohol use, despite an uncomplicated detoxification with benzodiazepine treatment. Conclusion: We hypothesise that the intake of country liquor in our patient, which contains higher percentages of alcohol, causes a prolonged imbalance of N-methyl-D-aspartic acid and glutamate receptor activity, leading to the picture of delayed-onset DT and that an atypical presentation at the time of admission and atypicality in early course are clinical pointers to the subsequent development of delayed-onset DT. Sahoo Saddichha 1 , Narayana Manjunatha 2 , Baxi Neeraj Prasad Sinha 3 , Christoday R.J. Khess 2 1 National Tobacco Control Program, WHO India, Kolkata, India; 2 Centre for Addiction Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, India; and 3 Clifton House, Teesdale South, Thornaby Place, Stockton-on-Tees, UK Keywords: delayed onset; delirium tremens Sahoo Saddichha, National Tobacco Control Program, WHO India, Kolkata, India. Tel: +919836530262; Fax: +916742572660; Email: saddichha@gmail.com Introduction Delirium tremens (DT), first described by Victor and Adams (1) as well as by Isbell et al. (2), is one of the most serious complications of alcohol withdrawal, affecting 5–10% of in-patients (3). DT has high mortality rate of up to 15% (3), which has been reduced to 2–5% (4) because of improved early treatment. There are several features described (5), which in most cases appear within 48–72 h of abstinence and persist for about 5–10 days, with 62% resolving in 5 days or less (6). Although DT typically remits over a period of several days (3), cases persisting for weeks have been reported (7). The risk factors for development of DT are presence of ongoing infection, tachycardia at admission, withdrawal signs with blood alcohol level more than 1 g/l, history of seizures or delirious episodes (5) or higher-than-usual quan- tity and frequency of ethanol consumption. We report a case of DT in a young man with delayed onset on the 15th day after the cessation of alcohol use, with a usual course of 4–5 days, despite an uncomplicated detoxification with benzodiazepine treatment. Case presentation Case history The patient was a 34-year-old married man, who at the time of admission was living with his wife and working as an attender in a school. He hailed from a semi-urban background and belonged to middle socio-economic class. He had been attending to his duties until several months before this admission when, because of his alcohol use, he began to absent himself from his job. He described himself as having been a Ôsocial drinker’ for the last 17 years who, over the preceding 6 years, had substantially increased his drinking in response to escalating job-related stress. On admission, he reported drinking between 1 and 2 l of country liquor daily, beginning each morning. He acknowledged having withdrawal tremors and tolerance, an inability to control his intake of alcohol and the presence of alcohol-related interpersonal and vocational problems. He also described difficulty in walking and carrying out any voluntary activities such as brewing coffee or tea, eating food with a spoon, holding a glass, etc. and signing any document holding a pen for the past 4 months, resulting in significant socio-occupational 152