Disulfiram-induced delirium: diagnostic dilemma

Disulfiram, a useful medication to deter the relapse of alcohol dependence, has been associated with a number of neuropsychiatric adverse effects. Disulfiram induced delirium is rare in the absence of an ongoing psychosis or a disulfiramethanol reaction. We present the case of an alcohol dependent patient who had a past history of both an alcohol-induced psychotic episode (which had resolved completely) and alcohol withdrawal seizure. Following inpatient detoxification and induction on disulfiram, to which he was compliant and maintaining totally abstinent, he developed an acute delirious state 6 weeks after disulfiram. It was characterized by fluctuating disorientation, marked inattention, affective lability, increased psychomotor activity, irrelevant speech, social disinhibition, at times staring, talking to self and gesturing in air, and sleep-wake cycle reversal with evening worsening of symptoms. He was re-hospitalized and symptoms subsided by 72 hours after stopping disulfiram. The diagnostic dilemma associated with such a presentation is discussed, along with the putative mechanisms and clinical pointers.