Case Presentation: A 14-year-old female, with a past medical history of marijuana use and superior mesenteric artery syndrome, presented with tremors, auditory, and visual hallucinations of 1 day duration. Her vital signs were notable for tachycardia ~120 bpm and hypertension (141/89). Her exam was significant for generalized tremors, linear scars from prior self-harm, and tongue fasciculations. The remainder of her exam was unremarkable, including neurological and cardiac. Labs were significant for elevated beta-hydroxybutyrate 3.3mmol/L (0.0-0.3 mmol/L), cannabinoids in the urine drug screen, urinalysis with ketones (>80 mg/dL), hyponatremia 131 mmol/L, metabolic acidosis with anion gap of 21, transaminitis (AST 141 units/L, ALT 56 units/L) blood alcohol level 0, and CBC with elevated MCV (102.4 fl). A CT head obtained for altered mental status was normal. The initial differential was suspicious for a toxidrome, cardiac, or neurological condition. Upon additional history, the patient endorsed drinking 1-5 beers/day with the last drink 1 day before symptoms onset. Despite her confession, most team members did not believe alcohol withdrawal was the primary disorder. A phosphatidylethanol test (PEth) was obtained to quantify her degree of alcohol use which was >900 ng/mL (>200 ng/mL signifying chronic use). The patient was managed on CIWA protocol and given lorazepam accordingly. The patient was safely discharged to inpatient psychiatric care for additional substance use management.
Discussion: Pediatric alcohol withdrawal syndromes are poorly reported in the literature and are difficult to recognize due to low clinical suspicion in this age group. However, by 12th grade, 58% of children report having consumed alcohol and 32% report being drunk before(1). About 2.9% of youth ages 12 to 17 were categorized as having alcohol use disorder(2). This epidemiologic data demonstrates that many teens have access to alcohol and are using alcohol frequently. Alcohol withdrawal is best managed in the hospital as this is one of the few withdrawal syndromes that can be deadly if undertreated or misdiagnosed. This patient demonstrated key features of withdrawal including sympathetic activation (hypertension and tachycardia), hallucinations, tremors, and anxiety. Important biomarkers of chronic alcohol use on routine laboratory testing include elevated liver enzymes in the pattern of AST>ALT and macrocytosis (3). Despite the constellation of symptoms and laboratory abnormalities consistent with withdrawal, there was both a lack of awareness and doubt of the cause. In these scenarios another biomarker, PEth, can be used to quantify recent alcohol use over a 2–4-week period. This test is not affected by age, sex, or other co-morbidities (3). The extremely high PEth supported the diagnosis and demonstrated chronicity.
Conclusions: Alcohol withdrawal can be difficult to recognize in children, though epidemiologic data support frequent use and access in this age group. Clinical data supporting this diagnosis include vitals, symptoms, physical examination, and laboratory studies. PEth testing is helpful in establishing chronicity, though, its use is limited during the acute phase of diagnosis and management of alcohol withdrawal.