DELIRIUM

The differential diagnosis of delirium is very similar to that for coma and one finds the mnemonic VINDICATE useful in this regard.

1. V—Vascular disorders of the brain including hemorrhage, embolism, thrombosis, and arteriosclerosis may cause delirium.
2. I—Inflammatory disorders of the nervous system that may cause delirium include viral encephalitis, meningitis, syphilis, malaria and other parasites, rabies, and cerebral abscess. Generalized infections, usually when associated with fever, may be responsible.
3. N—Neoplasms of the brain are not usually associated with delirium until the end stages at which time the cause will be obvious.
4. D—Deficiency disorders that may be associated with delirium include Wernicke encephalopathy, pellagra, and pernicious anemia. Delirium may be associated with degenerative disorders such as Alzheimer disease.
5. I—Intoxication by an enormous number of exogenous and endogenous substances may cause delirium. Alcohol, cocaine, heroin, phencyclidine (PCP), marijuana. lead, arsenic, and manganese levels are just a few of the exogenous substances. Endogenous substances include uremia, ammonia from hepatic failure, hyperinsulinemia, diabetic ketosis, and porphyria. Delirium may be associated with the withdrawal of a patient from alcohol and any drug including morphine, cocaine, and tobacco.
6. C—Convulsive disorders may be associated with delirium either during or after the seizure.
7. A—Autoimmune disorders such as lupus erythematosus are associated with inflammation of vasculitis in the brain causing delirium.
8. T—Trauma may cause a concussion, cerebral hemorrhage, subdural or epidural hematoma leading to delirium.
9. E—Endocrine disorders associated with delirium include insulinoma and diabetes.

Approach to the Diagnosis

It is essential to get a history of drug or alcohol use from the patient or family and a drug screen may be done in most cases. The workup should also include a CBC, sedimentation rate, urinalysis, ANA analysis, chemistry panel, and electrolytes. A CT scan or MRI of the brain will be necessary in most cases. It may be wise to administer intravenous thiamine and glucose while awaiting the results of blood work. If there is a fever, blood cultures and possibly a spinal tap (after a CT scan or MRI has ruled out a space-occupying lesion) may be indicated. Arterial blood gas analysis and carboxyhemoglobin should be determined. A neurologist or neurosurgeon needs to be consulted early in the workup.

Other Useful Tests

1. EEG (seizure disorder)
2. VDRL test (neurosyphilis)
3. Carotid sonogram (carotid thrombosis)
4. Four-vessel angiography (TIA)
5. Glucose tolerance test (diabetes, insulinoma)
6. Blood smear for malarial parasites (malaria)
7. Psychiatric consult
8. Urine porphobilinogen (porphyria)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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