A 35-year-old woman with alcohol use disorder is admitted for detoxification. She has been on diazepam taper. On day 5, she develops vivid, formed visual hallucinations of small animals and insects, with paranoid ideation and fluctuating consciousness but no significant autonomic instability. Her sensorium fluctuates. What is the most likely diagnosis?

• A Alcohol hallucinosis
• B Wernicke-Korsakoff syndrome
• C Schizophrenia
• D Delirium tremens ✓

Explanation

This patient has delirium tremens, which is defined by altered sensorium with fluctuating consciousness, vivid visual hallucinations, and paranoid ideation. Although autonomic instability may be less prominent (possibly blunted by benzodiazepines), the fluctuating sensorium distinguishes this from alcohol hallucinosis, which occurs with intact sensorium. Alcohol hallucinosis typically occurs earlier (24-48 hours) and patients remain fully oriented.

Reference: Harrison's Principles of Internal Medicine, 20th ed.

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